Corrective Action Plans

Finding 12962 (2022-002)

Significant Deficiency 2022

Peak Vista Community Health Centers, INC

CO

Reporting

Condition - Peak Vista is required to submit a Uniform Data System (UDS) Grant Report with the Health Resource and Service Administration (HRSA) with respect to the Health Center Program Cluster grants. Such report includes reporting certain line items such as Physician Clinic visits, Physician Virt...

Condition - Peak Vista is required to submit a Uniform Data System (UDS) Grant Report with the Health Resource and Service Administration (HRSA) with respect to the Health Center Program Cluster grants. Such report includes reporting certain line items such as Physician Clinic visits, Physician Virtual visits NPs, PAs and CNMs Clinic visits and NPs, PAs and CNMs Virtual visits. Recommendation - We recommend that Peak Vista's procedures be strengthened to ensure accurate reporting. Peak Vista should strengthen processes surrounding the review and reconciliation of supporting information used to complete the UDS Grant Report. Views of Responsible Officials and Planned Corrective Actions - Management agrees with the finding. Peak Vista has developed a plan for addressing this issue that includes updated procedures, training, and auditing. Additionally, the UDS Grant Report has been subsequently re-submitted. Anticipated Date of Completion - correction completed 06/01/2023 Action Taken - We have reviewed the recommendation and has developed a plan for addressing this issue. Person Responsible for Corrective Action Plan - Ryan Spillane, CFO

View Audit 17638

Finding 12959 (2022-002)

Significant Deficiency 2022

Rock Island County Regional Office of Education #49

IL

Reporting

FINDING 2022-002 - Controls Over Timely Expenditure Report Submissions Federal Program: Twenty-First Century Community Learning Centers, Education Stabilization Fund Project No.: 21-4421-13, 21-4421-15, 21-4421-25, 21-4998-EC Assistance Listing Number: 84.287C, 84.425C Passed-Through: Illinoi...

FINDING 2022-002 - Controls Over Timely Expenditure Report Submissions Federal Program: Twenty-First Century Community Learning Centers, Education Stabilization Fund Project No.: 21-4421-13, 21-4421-15, 21-4421-25, 21-4998-EC Assistance Listing Number: 84.287C, 84.425C Passed-Through: Illinois State Board of Education Federal Agency: U.S. Department of Education Condition: Rock Island County Regional Office of Education No. 49?s internal controls over expenditure report submission were not effective. It was noted that expenditure reports for Illinois State Board of Education grants were not submitted timely. Specifically, the following expenditure reports were not submitted timely: See Corrective Action Plan for chart/table Plan: A new Bookkeeper has joined the team at the Rock Island County Regional Office of Education and, in conjunction with the Regional Superintendent and grant program personnel, a specific process has been established to review the specific due dates of the expenditure reports at the onset of the fiscal year. All pertinent information that is necessary for the completion of the reports are identified by the Regional Superintendent, grant program personnel, and accounting department personnel to provide in a readily available format in order to ensure successful completion of the report by the due date. Additionally, dates are identified for when the reports will be submitted to ISBE which is well in advance of the due dates. All accounting personnel have been cross trained in the process for expenditure report submittal in order to ensure the reports are submitted to ISBE by the prescribed due dates. Anticipated Completion Date: Ongoing Contact Person Responsible for Corrective Action: Regional Superintendent, Tammy Muerhoff, Rock Island County Regional Office of Education No. 49

View Audit 17598

Finding 12950 (2022-002)

Significant Deficiency 2022

Catholic Charities of the Archdiocese of St. Paul and Minneapolis

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-002 Federal Agency Name: Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Program CFDA # 21.027 Finding Summary: Management has designed internal controls related to reporting, however, the controls were not formally documented. Responsible Individu...

Finding 2022-002 Federal Agency Name: Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds Program CFDA # 21.027 Finding Summary: Management has designed internal controls related to reporting, however, the controls were not formally documented. Responsible Individuals: Thomas Krolak Corrective Action Plan: A review of required reports will be done for each federal grant and the appropriate staff will be assigned to review and approved reports prior to submission Anticipated Completion Date: June 30, 2023

View Audit 17083

Finding 12938 (2022-002)

Significant Deficiency 2022

Irvington Community Schools, Inc.

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.334

Finding 2022-002 Document Retention (Significant Deficiency) Federal Program: Child Nutrition Cluster Finding: Per 7 CFR 200.334, ?Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of thre...

Finding 2022-002 Document Retention (Significant Deficiency) Federal Program: Child Nutrition Cluster Finding: Per 7 CFR 200.334, ?Financial records, supporting documents, statistical records, and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.? Management Corrective Action: While the school?s annual total meals served for the 2021-22 audit year were more than the meals claimed for reimbursement, the school was unable to reconcile all of the individual months. The school has since implemented and automated system to record lunches served. This point-of-sale system will eliminate the ongoing monthly accounting required to support monthly claims assuring the numbers served reconciles with the numbers claimed. Chris Ashmore has already implemented this system and tested the subsequent year-to-date audit period to assure this corrective action has, in fact, eliminated the problem.

View Audit 18123

Finding 12937 (2022-001)

Material Weakness 2022

Irvington Community Schools, Inc.

IN

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Finding 2022-001 Cash Management (Material Weakness) Federal Program: Child Nutrition Cluster Finding: Per 7 CFR 210.14(b) and 7 CFR 220.7(e)(1)(iv), the ?school food authority shall limit its net cash resources to an amount that does not exceed 3 months average expenditures for its nonprofit school...

Finding 2022-001 Cash Management (Material Weakness) Federal Program: Child Nutrition Cluster Finding: Per 7 CFR 210.14(b) and 7 CFR 220.7(e)(1)(iv), the ?school food authority shall limit its net cash resources to an amount that does not exceed 3 months average expenditures for its nonprofit school food service or such other amount as may be approved by the State agency Management Corrective Action: Previous audit year expenses were classified as ?General? funds when they should have classified as ?Food Service?. This, in aggregate, has led to an excess fund balance. Management, specifically Rod Iberg and Linda Heidrich, will work with the state on how to transfer the large arrear fund balances between accounts. Management will also endeavor to assure that all ongoing expenses are allocated to the correct fund.

View Audit 18123

Finding 12929 (2022-001)

Significant Deficiency 2022

Connecticut Harm Reduction Alliance, Inc.

CT

Reporting

Management will create a checklist of all reporting requirements with the applicable due dates to ensure that the reports are filed in a timely manner. The Finance Director and Chief Executive Officer will sign off on the checklist when the reports have been submitted.

View Audit 17684

Finding 12895 (2022-002)

Material Weakness 2022

City of East Chicago

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Valeriano F. Gomez / City Controller Contact Phone Number: 219-391-8300 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Additional Internal controls to address Finding 2022-002: A.- 1....

FINDING 2022-002 Contact Person Responsible for Corrective Action: Valeriano F. Gomez / City Controller Contact Phone Number: 219-391-8300 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: Additional Internal controls to address Finding 2022-002: A.- 1. East Chicago SLFRF reporting personnel, will be expanded to include a review of Quarterly Project and Expenditure Reports by a city senior accountant. 2. All personnel will jointly review Quarterly Project & Expenditure Report when completed, before proceeding to submission in portal. 3. Review by city personnel of previous Quarterly Reports to include the initial Interim Report (SLT-4798, 8-31-21) to address issues. 4. To address possible error in reporting tier will e-mail Treasury (SLFRF@treasury.qov.) for guidance and direction. Per Project and Expenditure Report User Guide April 1, 2023. B.- 2. East Chicago SLFRF reporting personnel will include the project ledger to future SLFRF Compliance Quarter Reports to ensure accurate reporting within the proper timeline / period. Note: In addition, with further discussion, we will continue to work on finding other proposals to improve internal controls issues related to Finding 2022-002. Anticipated Completion Date: Corrective actions should be in place for next SLFRF Quarterly Report (2nd Qtr. 2023).

View Audit 17648

Finding 12888 (2022-001)

Material Weakness 2022

Eastway Corporation

OH

Questioned Costs Reporting Internal Control / Segregation of Duties

2022-001 (a) Comments on Findings and Recommendations: While management concurs with the finding and auditors? recommendation to enhance internal controls to ensure reports are filed timely, it believes the failure to report the Period 2 funds was not due to neglect but simply due to the untimely de...

2022-001 (a) Comments on Findings and Recommendations: While management concurs with the finding and auditors? recommendation to enhance internal controls to ensure reports are filed timely, it believes the failure to report the Period 2 funds was not due to neglect but simply due to the untimely death of an employee. After the death of the Organization?s employee, management called the HRSA Provider Support Line, prior to the original due date of the reporting deadline, and was told that all reports had been filed. The Organization is currently working with HRSA to determine if an exception to the late filing can be obtained for reasonable cause based upon the previously mentioned circumstances. The Organization believes it has fully earned the Provider Relief Funds as it had sufficient lost revenues to support the need for the funding. (b) Action(s) Taken or Planned: Management is aware of the requirements related to the reporting submission. Management intends to implement proper procedures and policies for all grant reporting by June 30, 2023. Furthermore, internal controls over the program are being strengthened to prevent future non-compliance.

View Audit 17350 Questioned Costs: $1

Finding 12885 (2022-003)

Significant Deficiency 2022

Chief Dull Knife College

MT

Reporting

Finding 2022-3: Reporting Requirements Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College's website, but ...

Finding 2022-3: Reporting Requirements Reporting Requirements: Chief Dull Knife College will continue to review reporting requirements for all grants received. HEERF reports were posted to the College's website, but were not kept concurrent as they were required to be, but instead were replaced with the current report only, this procedure is being corrected and reviewed.

View Audit 17194

Finding 12878 (2022-004)

Material Weakness 2022

Brown County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2022-004 Julia Reeves Auditor Contact Person 812-988-5485 Contact Phone Number: Views of Responsible Official: I agree with the findings as they are listed. Description of Corrective Action Plan: Auditor?s office will Generate a report with a date range and keep the report on file for verifi...

FINDING 2022-004 Julia Reeves Auditor Contact Person 812-988-5485 Contact Phone Number: Views of Responsible Official: I agree with the findings as they are listed. Description of Corrective Action Plan: Auditor?s office will Generate a report with a date range and keep the report on file for verification to confirm report. The Auditor?s office will verify report before submission. Anticipated Completion Date: December 31, 2023

View Audit 17582

Finding 12873 (2022-001)

Significant Deficiency 2022

Hall County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.403

FA 2022-001 Improve Controls over Federal Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Im...

FA 2022-001 Improve Controls over Federal Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.4250 - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary And Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) S45U210012 (Year: 2021) Questioned Costs: $116,610 Repeat of Prior Year Finding: None Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: We concur with the auditor?s reasoning that the contract terms for services should have been modified to reflect the one-time retention payments for contracted custodial personnel. Retention of contracted custodial staff members was deemed by the District to be an essential part of its effort to ensure clean, sanitary facilities in response to COVID-19 pandemic. ? The District has several internal controls in place to determine and verify the allowability of ESSER expenditures, which include: ? Authorization by the Hall County Board of Education. ? Authorization by the Georgia Department of Education through the ESSER program?s consolidated application. ? Approval of all ESSER payments and purchase orders by relevant personnel familiar with the allowability requirements of the ESSER program. ? Approval of all ESSER contract agreements by relevant personnel familiar with the allowability requirement of the ESER program. ? Documented protocols for determining District personnel eligible to be paid through ESSER funds. The District will conduct a review of its contract with third party service providers to ensure compliance with Uniform Grant Guidance. The District currently has no further plans for the provision of additional retention payments to contracted personnel using ESSER funds, and no additional corrective action is anticipated to be required for the isolated instance. Estimated Completion Date: March 31, 2023 Contact Person: Jonathan C. Boykin Telephone: 770-534-1080 Email: jonathan.boykin@hallco.org

View Audit 17388 Questioned Costs: $1

Finding 12866 (2022-003)

Material Weakness 2022

Wagner Community Memorial Hospital

SD

Reporting Material Weakness Matching / Level of Effort / Earmarking

Finding 2022-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing/CFDA #10.766 Program Name: Communities Facilities Loans and Grants Cluster Compliance Requirement: Preparation of the Schedule of Expenditures of Federal Awards Finding Summary: Eide Bailly LLP prep...

Finding 2022-003 Federal Agency Name: Department of Agriculture Federal Financial Assistance Listing/CFDA #10.766 Program Name: Communities Facilities Loans and Grants Cluster Compliance Requirement: Preparation of the Schedule of Expenditures of Federal Awards Finding Summary: Eide Bailly LLP prepared our draft Schedule of Expenditures of Federal Awards and accompanying notes to the schedule. Responsible Individuals: Lisa Weisser, Director of Finance Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule of Expenditures of Federal Awards. We requested that our auditors, Eide Bailly LLP, prepare the Schedule of Expenditures as part of their Single Audit. We have designated members of management to review the drafted Schedule and accompanying notes. Anticipated Completion Date: Ongoing

View Audit 17145

Finding 12855 (2022-002)

Significant Deficiency 2022

Elm Hill Water District

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.

View Audit 17759

Finding 12825 (2022-001)

Material Weakness 2022

West Central Illinois Area Agency on Aging

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed and signed by the director or assistant director of the agency before being su...

Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed and signed by the director or assistant director of the agency before being submitted to the grantor. A report comparing the cash request amounts made to the grantor to the general ledger has been implemented effective January 31,2023. A procedure is also being developed to periodically monitor adherence to various grant requirements, as well as the development of documentation to support personnel activity tied to grants. The fiscal department intends to implement these effective June 30, 2023.

View Audit 17744

Finding 12823 (2022-001)

Significant Deficiency 2022

Pennsylvania Institute of Technology and Subsidiaries

PA

Subrecipient Monitoring Reporting

FINDING 2022-001: COVID-19 - Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425E Student Aid Portion/ 84.425F Institutional Portion Recommendation: The College should assign an individual to track reporting requirements of awards to ensure the College is in compliance an...

FINDING 2022-001: COVID-19 - Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425E Student Aid Portion/ 84.425F Institutional Portion Recommendation: The College should assign an individual to track reporting requirements of awards to ensure the College is in compliance and identify a designated reviewer for the information posted to the College?s website. The College should post the information required under the Student Aid Portion to its website in accordance with the ED guidelines. Action Taken: The College has updated its website on October 15, 2022 with the information regarding the Student Aid Portion distributed under HEERF II and III to its website in accordance with the ED guidelines. The College President and Director of Financial Aid will be responsible for ensuring that the website posting deadline has been met by monitoring this activity each quarter. Responsible Individual for Corrective Action: Laura Blomgren, Director of Student Financial Aid Completion Date: October 15, 2022

View Audit 17737

Finding 12810 (2022-002)

Significant Deficiency 2022

Milwaukee Area Technical College

WI

Student Financial Aid Reporting

Finding No. 2022-002 ? Report Filed After Due Date Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: By October 1 the institution should submit its...

Finding No. 2022-002 ? Report Filed After Due Date Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: By October 1 the institution should submit its ED Form 646-1, Fiscal Operations Report, and Application to Participate (FISAP) that includes the Fiscal Operations Report for the preceding award year and the Application to Participate for the upcoming award year (FWS, FSEOG 34 CFR 673.3; Fiscal Operations Report and Application to Participate Instructions). Condition / Context: The FISAP for award year 2021-2022 was filed on October 12, 2022. Our sample was statistically valid. Cause: As MATC approached the deadline for FISAP submission, responsible MATC personnel were not aware of the outstanding reporting items and the immediate need to employ an alternative plan to ensure the timely submission of the FISAP. Questioned Costs: Unknown Effect: This electronic report is submitted annually to receive funds for the campus-based programs. The institution uses the Fiscal Operations Report portion to report its expenditures in the previous award year and the Application to Participate portion to apply for the following year. Delays in filing of this report could result in delays with subsequent year funding. Recommendation: MATC should implement a reporting calendar, including deadlines for draft, review and approval of the FISAP to ensure timely filing. District Response: MATC agrees with the finding and has developed, documented and implemented a process and calendar to ensure timely completion of the annual FISAP. Al Pinckney, Executive Director of Financial Aid 12/6/2022

View Audit 17732

Finding 12808 (2022-004)

Significant Deficiency 2022

Milwaukee Area Technical College

WI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding No. 2022-004 ? Reporting Discrepancies - Enrollment Repeat Finding: 2021-001 ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: Institutions are required to re...

Finding No. 2022-004 ? Reporting Discrepancies - Enrollment Repeat Finding: 2021-001 ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: Institutions are required to report enrollment information under the Pell grant and the Direct and FFEL loan programs via the NSLDS (OMB No. 1845-0035). Institutions must review, update and verify student enrollment statuses, program information, and effective dates that appear on the Enrollment Reporting Roster file or on the Enrollment Maintenance page of the NSLDS Professional Access (NSLDSFAP). Condition / Context: We selected a sample of 25 Pell and Direct Loan students from the institution's records that had a reduction or increase in attendance levels, graduated, withdrew, dropped out or enrolled but never attended during the audit period. We compared the data in the students' NSLDS Enrollment Detail to the students' academic files and other institutional records and verified that the institution is accurately reporting the significant Campus-Level and Program-Level enrollment data elements that ED considers high risk. Of the 25 sampled, 10 had discrepancies between the status documented in MATC's institutional records and the status reported on the NSLDS. Our sample was not statistically valid. Cause: In April 2021, the National Student Clearinghouse made a change to its reporting process, which resulted in errors in MATC's data uploads. MATC has begun the process of testing and correcting its process, but this was not completed as of June 30, 2022. MATC believes this update error has caused the continued discrepancies between MATC and the NSLDS. Questioned Costs: Unknown Effect: The administration of the Title IV programs depends heavily on the accuracy and timeliness of the enrollment information reported by institutions. Incorrect reporting of enrollment status could result in incorrect distribution of Title IV funds to institutions or individuals. Recommendation: We recommend MATC continues its review process for enrollment statuses, and provide additional training for management and staff to ensure the correct statuses are reported and that control processes are operating effectively to ensure proper returns. District Response: The Office of the Registrar has developed and is implementing an action plan to ensure correct reporting through the National Clearinghouse and NSLDS. The process includes additional staff training, review and update of the submissions process and schedule and enlisting support from specific contacts at the Clearinghouse. These steps were completed by September 2022. Additional steps, including review of the reporting setup the SIS system with the IT department, discussing and resolving existing issues with the Clearinghouse, performing checks of individual current and prior year students to identify and correct additional gaps, incorporating a regular review of a sample of students for proper reporting and hiring additional staff for reporting enrollment ? all to be completed by December 2022. Beginning in 2023, staff will also create and submit an additional report to the Clearinghouse for each submission of graduates and creating a position to lead enrollment reporting. Dr. Sarah Adams, Dean of Enrollment Services 12/6/2022

View Audit 17732

Finding 12770 (2022-001)

Significant Deficiency 2022

Humility Homes and Services, Inc.

IA

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Corrective action taken: Management will implement policies and procedures to ensure reports are reviewed and submitted timely in accordance with grant requirements.

View Audit 17728

Finding 12728 (2022-002)

Significant Deficiency 2022

Hot Springs County

WY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

Audit Finding 2022-002 Finding Lack of Written Policies and Procedures over Federal Awards ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Corrective action plan in progress Corrective Action Plan In response to the finding...

Audit Finding 2022-002 Finding Lack of Written Policies and Procedures over Federal Awards ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Corrective action plan in progress Corrective Action Plan In response to the finding, the County is in the process of developing written policies and procedures relative to internal controls over federal awards, to help achieve: - County wide consistency over compliance regulations and standards - Decrease the risk of grant agreement noncompliance - Reduce the risk of undetected errors in processing of financial transactions relative to federal awards. Steps taken include: - Familiarization of requirements in 2 CFR 200.303 - Obtain draft examples of policies and procedures adopted by other Counties - Discussion with governance and county attorney regarding development and adoption of policies and procedures In addition, the County is continuing to suggest departments implement effective internal control structures to - Protect assets against theft and waste - Ensure accurate and reliable operating and accounting data The conditions noted in this finding were previously reported in finding 2021-002 Completion Date Estimated June 2023 - policy written, approved by Commissioners, and disseminated ot departments Training - ongoing County Contact Becky Kersten, County Clerk

View Audit 17708

Finding 12725 (2022-001)

None 2022

Rodeo Senior Apartments, Inc.

CA

Questioned Costs HUD Housing Programs Reporting

Finding Number Planned Corrective Action Anticipated Completion Date Responsible Contact Person 2022-001 Management Agent will refund all amounts owed to property per Audit finding. Going forward only HUD approved fees will be charged to property. 12/31/2022 Bipin Patel ? Accounting Manager

View Audit 17646 Questioned Costs: $1

Finding 12722 (2022-001)

Material Weakness 2022

Legacy Health

OR

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund porta...

Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund portal. Additionally, Legacy claimed expenses that were duplicated within the reporting portal. The general distribution report for Legacy Health for Period 1 shows $35,760,843 in expenses applied against the PRF funds in the PRF portal report for Legacy as a consolidated entity. Separately, the stand-alone reports for targeted funds received by Emanuel Hospital & Health Center for Period 1, Legacy Silverton Medical Center for Period 1, Legacy Clinics, LLC for Period 1, and Legacy Meridian Park Hospital for Period 2 also include expenses totaling $12,291,293 that are included in the $35,760,843 listed in the consolidated report above. This results in duplicate reporting of the same expenditures. During testing over reporting and allowability it was observed that the lost revenues attributable to Coronavirus were reported in both the parent entity?s PRF reports on the general distribution payments and the subsidiary entities? PRF reports on the targeted distribution payments (i.e., lost revenues were duplicated). Lost revenues shown on the subsidiary reports as available to be applied against PRF that related to lost revenues also reported in the parent entity?s report were related to Emanuel Hospital & Health Center for Period 1 in the amount of $27,106,110 and Legacy Silverton Medical Center for Period 1 in the amount of $10,269,349. Actions Taken and Status As noted within the portal filing summary, for reporting period 1, Legacy consolidated COVID-19 expenses ($35,760,843) plus lost revenue ($150,037,450) totaled $185,798,293. Payments from the PRF totaled $89,818,954. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the questioned costs above. Therefore, management believes no repayment of PRF funds received would be required. Further, management considered the finding. Reporting for the Legacy parent reporting entity was based on the ?Post-Payment Notice of Reporting Requirements (6/11/21)?, which includes the following requirement: ?Reporting entities will submit consolidated reports.? Neither the methodology utilized by Legacy or application of the methodology advocated by KPMG result in repayment of any of the funds received from the PRF. Management is implementing a process to identify and resolve situations in which reporting requirements are inconclusive, in conflict, or ambiguous. Outside subject matter expertise will be accessed as needed. Person responsible for the implementation of the corrective action plan: Tom Haywood Legacy Health 1919 NW Lovejoy St Portland OR 97219 503-415-5793 thaywood@lhs.org

View Audit 17558 Questioned Costs: $1

Finding 12721 (2022-003)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Reporting Internal Control / Segregation of Duties

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verificati...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verification with funders should be performed as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name(s) of the contact person(s) responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.

View Audit 17548

Finding 12717 (2022-002)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties

SIGNIFICANT DEFICIENCY 2022-002 Audit misstatements Recommendation: We recommend that management review policies and procedures over year-end transactions to ensure that all necessary adjustments are being posted on a timely basis, in the appropriate period, and in accordance with generally accep...

SIGNIFICANT DEFICIENCY 2022-002 Audit misstatements Recommendation: We recommend that management review policies and procedures over year-end transactions to ensure that all necessary adjustments are being posted on a timely basis, in the appropriate period, and in accordance with generally accepted accounting principles. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.

View Audit 17548

Finding 12716 (2022-001)

Material Weakness 2022

The Inner Voice, Inc.

IL

Internal Control / Segregation of Duties Material Weakness Reporting

MATERIAL WEAKNESS 2022-001 Financial Reporting Recommendation: The financial statement preparation process s...

MATERIAL WEAKNESS 2022-001 Financial Reporting Recommendation: The financial statement preparation process should be part of the internal control system, although the Inner Voice may be financially limited in the hiring of personnel with an up-to-date understanding of accounting preannouncements, proper mitigating factors should be reflected including oversight by management. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.

View Audit 17548

Finding 12699 (2022-004)

None 2022

Kindred Public School District

ND

Reporting School Nutrition Programs § 200.512

2022-004 UNTIMELY FILING OF THE DATA COLLECTION FORM ? OTHER NONCOMPLIANCE Condition: The Kindred Public School District did not submit its Data Collection Form to the Federal Audit Clearinghouse within nine months of its year-end. Corrective Action Plan: Agree?We had many things going on this ...

2022-004 UNTIMELY FILING OF THE DATA COLLECTION FORM ? OTHER NONCOMPLIANCE Condition: The Kindred Public School District did not submit its Data Collection Form to the Federal Audit Clearinghouse within nine months of its year-end. Corrective Action Plan: Agree?We had many things going on this year with Superintendent hiring and construction. Anticipated Completion Date: Was done as soon as audit was complete.

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