Corrective Action Plans

Finding 404941 (2021-008)

None 2021

Clark County Fiscal Court

KY

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

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

View Audit 311338

Finding 404909 (2021-005)

Significant Deficiency 2021

Iroquois Memorial Hospital

IL

Internal Control / Segregation of Duties Reporting Significant Deficiency

The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Gui...

The CFO of Iroquois Memorial Hospital and Resident Home worked in fiscal year 2024 to catch up past audits and is working to catch-up account reconciliations and have proper support for balances within the general ledger and financial statements. This will also allow for timely filing of Uniform Guidance audits in the future. The audits for the years ended September 30, 2023, 2022, and 2021, were completed and dated June 28, 2024; whereas under prior management of the hospital the last financial statement for the year ended September 30, 2020 was completed by the current management team in 2023 as was left uncompleted by prior hospital management. The team at the Organization plans to continue to be timely with audits in the future.

View Audit 311307

Finding 404908 (2021-004)

Significant Deficiency 2021

Iroquois Memorial Hospital

IL

Allowable Costs / Cost Principles Cash Management Reporting

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under th...

The CFO and accounting team at Iroquois Memorial Hospital and Resident Home worked with its financial statement auditors and the HRSA audit support desk for Provider Relief Funds to identify a plan to update its documentation as well as update its internal records to reflect allowable costs under the program. One of the updates included utilization of additional lost revenue to cover nonallowable expenses under the first phases of reporting for Provider Relief Funds due to elimination of some expenses and reduction for Medicare cost reimbursement against expenses. Management developed a more detailed expense log and review those against current terms and conditions prior to any future portal submissions and took into account the use of additional lost revenue. The worksheets were mocked up internally as if these were submitted in the portal in Phase I reporting so that in the future for the next phases of reporting, these lost revenues are not utilized toward future Provider Relief Funding. One additional control being added for this reporting is that the CEO and CFO will be also completing a detailed review of the spreadsheets for entry into the portal and comparing this to the Compliance Supplement which governs the use of the Provider Relief Funds as to allowable costs as well as the Frequently Asked Questions (FAQs) available on HRSAs website. This may impact future reports, so management will ensure to take these updates into account on any future provider relief funds are they are released or future grant receipts if the Organization receives new grants in the future.

View Audit 311307

Finding 404821 (2021-007)

Material Weakness 2021

Shattuck Hospital Authority D/b/a Newman Memorial Hospital, Inc.

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024

View Audit 311207

Finding 404820 (2021-006)

Material Weakness 2021

Shattuck Hospital Authority D/b/a Newman Memorial Hospital, Inc.

OK

Reporting Material Weakness

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority does not ha...

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the schedule Corrective Action Plan: Due to cost considerations, we will continue to have our auditor prepare our draft schedule of expenditures of federal awards. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: Ongoing

View Audit 311207

Finding 403385 (2021-001)

Material Weakness 2021

Oficina Del Procurador De Las Personas De Edad Avanzada

PR

Internal Control / Segregation of Duties Material Weakness Reporting § 200.512

As we mentioned in the SA 2020 Corrective Action Plan, we expected to finish SA 2021 in FY 2023, as well as SA 2022. We were not able to achieve this goal as face-to-face work had not yet been fully normalized due to a Pandemic Covid-19.Normality in terms of face-to-face work was fully implemented i...

As we mentioned in the SA 2020 Corrective Action Plan, we expected to finish SA 2021 in FY 2023, as well as SA 2022. We were not able to achieve this goal as face-to-face work had not yet been fully normalized due to a Pandemic Covid-19.Normality in terms of face-to-face work was fully implemented in 2022-2023. We currently have a contract to achieve the SA 2022 which will start in April 2024. We will continue to enter into a unified contract to achieve SA 2023 and SA 2024 completion on or before December 31, 2024. We have worked hard planning for this goal.

View Audit 310511

Finding 403374 (2021-008)

Significant Deficiency 2021

First Choice Community Healthcare, Inc.

NM

Reporting

2021-008—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Offic...

2021-008—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024

View Audit 310507

Finding 403370 (2021-009)

Material Weakness 2021

First Choice Community Healthcare, Inc.

NM

Reporting § 200.512

2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date:...

2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024

View Audit 310507

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Questioned Costs Reporting 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

Finding 402375 (2021-013)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Material Weakness Reporting

Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Comp...

Health Care Services understands the finding that amounts identified in the single audit as Medicaid and CHIP “pass through payments to subrecipients” could be subject to the FFATA. Pursuant to Office of Management and Budget (OMB) Guidance, Title 2 of the CFR, Parts 170 and 200.1, and the OMB Compliance Supplement, a subrecipient is an entity “that receives a subaward from a pass-through entity to carry out part of a Federal award,” and a subaward “does not include payments to a contractor or payments to an individual that is a beneficiary of a Federal Program.” Health Care Services will review current practices for managing subawards and payment classifications to ensure payments subject to FFATA are appropriately reported and update current practices as applicable by June 2024. Estimated Implementation Date: June 2024 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913

Finding 402372 (2021-012)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Reporting Significant Deficiency

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA re...

The Department of Aging (Aging) is committed to rectifying this issue and coming into compliance with this reporting requirement effective now. Aging has reworked the roles and responsibilities within the Budget Operations Bureau to ensure that there is a dedicated staff person to enter all FFATA reporting within the required timeframe. This individual has been trained and made aware of the expectations. Aging has begun updating the FFATA records and will continue this effort through the month of March until all reporting has been completed. Moving forward, the dedicated staff person will update the FFATA for each new federal funding award within the required timeframe. Estimated Implementation Date: March 2023 Contact: Kim Elliott, Chief Budget Officer Division of Administrative Services California Department of Aging

View Audit 309913

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 309913

Finding 402364 (2021-008)

Material Weakness 2021

State of California

CA

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

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law D...

Health Care Services agrees with the recommendation and implemented corrective action by October 31, 2022. Health Care Services, or DHCS, published Behavioral Health Information Notice (BHIN) 22-045 which outlines Health Care Services sanctions policy. The BHIN states “Under state and federal law DHCS must enforce compliance with the terms of the DHCS’ contracts with Mental Health Plans and Drug Medi-Cal Organized Delivery System counties, as well as ensure compliance with applicable state and federal laws and regulations, in accordance with its authority and obligations under state and federal requirements.” Lastly, under the section titled ‘Exhibit A - Attachment 3’ of the County Mental Health Plan Contract counties are required to submit cost reports timely which would allow Health Care Services to impose sanctions on counties who do not submit cost reports in a timely manner. This BHIN resolves the finding. Additionally, Health Care Services will not be collecting cost reports for dates of service after State Fiscal Year 2022-23. Under the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and pursuant to Welfare and Institutions Code, Section 14184.403(b), Health Care Services will replace the current Certified Public Expenditures (CPE) reimbursement methodology with an intergovernmental transfer (IGT) reimbursement methodology. The IGT reimbursement methodology will make a single and final payment for services provided to the county, which includes the non-federal portion of the claims. This change will eliminate the requirement for the county submission of cost reports. Estimated Implementation Date: October 31, 2022 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913

Finding 402363 (2021-007)

Significant Deficiency 2021

State of California

CA

Subrecipient Monitoring Reporting § 200.303 § 200.332 § 200.414 § 200.502

California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding...

California Business, Consumer Services and Housing Agency (BCSH) The California Interagency Council on Homelessness (Cal ICH), an entity under the BCSH, would like to acknowledge a finding from the fiscal year 2020-21 Statewide Federal Compliance Audit of the State of California. This audit finding identifies lack of communication of required subaward information to Cal ICH subrecipients of the Coronavirus Relief Fund (CRF) program at the time of the subaward, or when the State became aware of changes in subaward information, including identification that the subaward funds represented federal funding. Cal ICH agrees with this finding and the recommendation to review all subawards provided which were funded using CRF program funds and determine whether the subrecipients properly reported their CRF awards and related expenditures in their respective schedule of expenditures of federal awards pursuant to Title 2 Code of the Federal Regulations 200.502. Additionally, while formal communication identifying that the subaward fund represented federal funding was not provided, many informal conversations were had with CRF grantees. These conversations were held during bi-weekly online Office Hours and through one-on-one calls with individual subrecipients and discussions of the substitution of federal awards with grantees originally provided with State funds could have occurred. Cal ICH will conduct review of the CRF subawards during mandatory desk reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Additionally, Cal ICH has developed an improved communication system between leadership and program staff that will ensure changes are clearly communicated. This will also ensure the Council’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Additionally, if in the future funding is changed, CDE will provide updated information to all recipients; this will ensure that expenditures are in line with the terms and conditions of the grant and/or funding source. Estimated Implementation Date: May 2023 Contact: Ellen Meuchel, Monitoring Unit Cal ICH Grant Operations and Suppor California Department of Education Concur. Education will review the relevant subawards funded under the CRF program and determine whether the subrecipients properly reported their CRF awards pursuant to 2 CFR 200.501. Estimated Implementation Date: July 31, 2023 Contact: Kelly Levario, External Audits Coordinator Audits and Investigations Division California Department of Social Services The California Department of Social Services (CDSS) acknowledges the Single Audit finding regarding the delayed communication of subaward information to the Department’s subrecipients of the Coronavirus Relief Fund (CRF) program. On December 21, 2022, CDSS released County Fiscal Letter 22/23-31 on the subject of “Federal Coronavirus Relief Funds That Replaced General Fund for COVID-19 Related Activities for Fiscal Years 2019-20 and 2020-21” to County Welfare Departments (CWDs) and federally recognized Tribal governments in California. This letter served as a formal documentation of the portion of expenditures that were funded with federal CRF. Additionally, although formal notice was not provided until December 21, 2022, informal notices and conversations took place between CDSS and the County Welfare Directors Association, as well as with CWDs, regarding possible situations in which the substitution of federal awards with grants originally provided with State funds could occur. On September 21, 2021, CDSS sent a notice to subrecipients requesting for their Data Universal Number System for the purpose of CRF federal subawards; thereby, communicating the use of CRF on the subrecipients’ behalf. CDSS will conduct a review of the CRF subawards during on-site fiscal monitoring reviews to verify that subrecipients properly reported their CRF awards and that expenditures of the federal awards were made pursuant to Title 2 Code of Federal Regulations 200.502. Moreover, CDSS will ensure that the Department’s subrecipients are notified in a timely manner upon any changes in subaward information, such as identifying if subaward funds represent federal funding so that expenditures are spent in accordance with Federal statutes, regulations, and the terms and conditions of federal awards. Estimated Implementation Date: April 2023 through June 2024 Contact: Elisa Tsujihara, Chief Fiscal Policy and Analysis Bureau

View Audit 309913

Finding 402361 (2021-006)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Allowable Costs / Cost Principles § 200.303

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California ...

The EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete any remaining retroactive workload by April 30, 2023. Estimated Implementation Date: January 2021 Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402359 (2021-005)

Material Weakness 2021

State of California

CA

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

Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Condit...

Given the unprecedented volume of unemployment insurance claims during the federal disaster -approximately 20 million claims compared to 3.8 million during the Great Recession - EDD took action to speed payments to eligible claimants whenever possible. For example, EDD launched in July 2021 a Conditional Payment Program to speed payments to claimants who certified for benefits and already received at least one week of benefits in the past but whose payments were later pending for more than two weeks. EDD also boosted its capacity to process workloads, prioritized timely payments, and employed automation among other measures. As reported in Reference Number 2020-006 in fiscal year 2019-2020, EDD began automatically cross-matching EDD wage records and Franchise Tax Board (FTB) records in November 2020 to assist in verifying the income of PUA claimants. Claimants who could not be automatically verified through the FTB wage record match were required to submit additional documentation to EDD for a manual review. Regarding the manual processing of the income documents to substantiate the PUA weekly benefit amounts that have been increased above the minimum California weekly benefit amount (WBA) of $167, in June 2022, the EDD submitted a blanket waiver application to the U.S. Department of Labor (DOL), pursuant to the DOL Unemployment Insurance Program Letter 20-21, Change 1. EDD’s application is pending the DOL’s determination. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, failed to provide proof of income substantiation to support the increase or whose WBA will be decreased because the proof they provided was insufficient. Regarding the verification of employment or self-employment substantiation (known in California as “Self-employment/Employment Substantiation” or “SEES”), this verification process is being implemented in two phases. Phase 1 of the SEES effort was implemented on November 10, 2021, and involved notifying claimants registered in California’s UI Online (UIO) system by email and text of their requirement to provide SEES documentation. Phase 2 will involve notifying claimants who did not respond to the UIO request for SEES documentation, and those who are not registered in UIO, via a paper notice mailed through the United States Postal Service (USPS). EDD submitted a blanket overpayment waiver application in June 2022 to DOL regarding this issue. EDD will assess further implementation based on the DOL’s decision. If approved, our blanket waiver application would cover any overpayments for claimants who, through no fault of their own, provided insufficient documentation or did not provide any documentation. Estimated Implementation Date: To be determined once the DOL provides a decision on the waiver application. Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402354 (2021-002)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.502 § 200.510

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will up...

Public Health’s Accounting Office will generate the FI$Cal Year End Close report (KK_12 expenditure) and collaborate with the ELC program to ensure that all expenditures captured are complete and accurate, ensuring timely reporting of the SEFA data for FY 2023-24 and beyond. Additionally, we will update the procedures to document the SEFA reporting for the ELC program.

View Audit 309913

Finding 402351 (2021-001)

Material Weakness 2021

State of California

CA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (...

EDD agrees with this finding. The deferred transition to FI$Cal and the difficulties experienced thereafter have continued to cause EDD to be late with submitting year-end financials and its ability to submit timely the cash basis expenditures into the Single Audit Expenditures Reporting Database (Database). In addition, the onset of the COVID-19 pandemic created additional issues which ultimately impacted the EDD’s ability to submit timely year-end financials. However, the EDD is making progress and continues to gain ground in the department’s efforts to follow the State’s deadlines for submitting year-end financials and entering the cash basis expenditures into the Database. By the end of fiscal year 2021-22 and into fiscal year 2022-23, the EDD did a restructuring within the accounting area which realigned workload amongst the units and provided additional resources in critical areas. These changes will have a lasting effect and help the department to be better positioned going forward in processing the accounting workload and ultimately be able to catch up and submit year-end financials and enter the cash basis expenditures into the Database by the State’s deadlines. In addition, the EDD took lessons learned from the fiscal year 2019-20 financial audit to update processes and procedures and applied that knowledge going forward. Also, staff have been participating in various trainings offered by Finance and the Department of FISCal and staff continue to work with the control agencies when issues arise that would impact our accounting functions. While the EDD is still behind, the department is making great progress on catching up. The EDD submitted the last of its fiscal year 2020-21 financials in July 2022 and is targeting to submit the last of its fiscal year 2021-22 financials by the end of March 2023. The EDD’s goal is to submit fiscal year 2022-23 financials by the end of December 2023. Similar to the 2019-20 financial audit, the EDD will take the knowledge learned during the 2020-21 audit season, continue to engage with the control agencies, and continue to train and develop staff in order to keep progressing towards the department’s goal of becoming timely with the submission of the year-end financials and entering of the cash basis expenditures into the Database.

View Audit 309913

Finding 401358 (2021-003)

Significant Deficiency 2021

Institute of Forensic Sciences

PR

Reporting Matching / Level of Effort / Earmarking § 200.512

Reportable Condition: The Institute did not submit the Data Collection Form and Reporting Package to the Federal Audit Clearinghouse of the fiscal year in June 30, 2021 during the required period. Recommendation: We recommend the institute to maintain adeq...

Reportable Condition: The Institute did not submit the Data Collection Form and Reporting Package to the Federal Audit Clearinghouse of the fiscal year in June 30, 2021 during the required period. Recommendation: We recommend the institute to maintain adequate accounting records related to the non-federal and federal funds in order to properly prepare the financial statements accurrate and in a timely manner. Action Taken: As previously stated, our new accounting system (MIP) will keep our accounting records on a precise manner, improving our internal controls and providing us the opportunity to prepare the financial statements with fulll correctness and accuracy, also complying with the terms established and regulated.

View Audit 309460

Finding 401250 (2021-001)

Significant Deficiency 2021

Presbyterian Homes of Tennessee, Inc.

TN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Department of Health and Human Services Presbyterian Homes of Tennessee, 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 disc...

Department of Health and Human Services Presbyterian Homes of Tennessee, 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: The organization updated the submission related to its Period 1 reporting, which included an updated lost revenue calculation to support all provider relief fund payments received. The organization should ensure the proper review procedures are in place for any future submissions to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An amended Period 1 submission report, using the lost revenues, was submitted. Appropriate review procedures will be put in place to ensure accurate reporting on any future submissions. Name of the contact person responsible for corrective action: Erik Hockman, CFO Planned completion date for corrective action plan: May 2, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Erik Hockman at 865-243-3613.

View Audit 309260

Finding 401147 (2021-002)

Significant Deficiency 2021

Public Hospital District No. 1 of Skagit County

WA

Reporting § 200.510

Finding 2021-002 Responsible Official: Donnie Gosnell, Controller Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put in place to compile the SEFA, reconcile to support and perform a related r...

Finding 2021-002 Responsible Official: Donnie Gosnell, Controller Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put in place to compile the SEFA, reconcile to support and perform a related review prior to audit. In addition, grant agreements will be required to go through the contract approval process. This will allow all grants to be identified and tracked, ensuring completeness. This has been implemented as of March 2024

View Audit 309195

Finding 401146 (2021-001)

Significant Deficiency 2021

Public Hospital District No. 1 of Skagit County

WA

Matching / Level of Effort / Earmarking Reporting Significant Deficiency § 200.303

Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the differ...

Finding 2021-001 Responsible Official: Matthew Vaughn, Regional Director of Financial Planning & Analysis Views of Responsible Officials: The District believed they were in compliance with the reporting requirements at the time of submission based on the guidance available. Guidance among the different federal programs changed over the course of the Public Health Emergency in a manner that caused reconsideration of both the classification and estimate of expenses. Over the course of the pandemic, the district went through the process to more completely segregate the PRF support from other COVID-19 funding. While the allocations and classifications within the program reports would have changed based on that process, in total program expenditures for both periods in total were supported. All expenses under the Public Health Emergency period have currently been categorized in this manner, and any future expenses or expense adjustments will be kept with this categorization in-tact. This was completed over the course of the 2021 Single Audit review in November 2023

View Audit 309195

Finding 400966 (2021-004)

Material Weakness 2021

Gloversville Housing Authority

RI

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the F...

Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the Authority will ensure annual audits are conducted and timely electronic submissions of GAAP-based unaudited and audited financial information to HUD through the FASS-PH system. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director

View Audit 309030

Finding 400880 (2021-001)

Significant Deficiency 2021

Indiana Senior Housing Health Care Properties, Inc.

IN

Reporting Significant Deficiency

Views of Responsible Officials and Planned Corrective Action – Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and will file the single audit reporting package as soon as possible.

View Audit 308908

Finding 400853 (2021-004)

Material Weakness 2021

Camden County Board of Social Services

NJ

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticip...

Corrective Action Plan: All Bank Reconciliations will be reviewed for the Assistance and Clearing Fund. All unidentified adjustments will be researched, and adjustments will be made on the corresponding reports submitted to the Division of Family Development. Responsible Party: Accountant Anticipated Completion Date: Immediately

View Audit 308868

Corrective Action Plans

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