Corrective Action Plans

Finding 392366 (2021-001)

Significant Deficiency 2021

KS

Reporting Significant Deficiency

The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-C...

The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-COVID related service should have been excluded from the comparison period. The Hospital will correct the lost revenue calculations to exclude new non-COVID related patient care revenues in both the baseline and comparison periods in all subsequent PRF reporting.

View Audit 302715

Finding 392314 (2021-006)

Significant Deficiency 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

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

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 302660

Finding 392313 (2021-005)

Material Weakness 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Internal Control / Segregation of Duties Material Weakness Period of Performance

2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type...

2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type of Finding: • Material Weakness in Internal Control over Compliance • Other Matters (Modified Opinion) Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: CLA was unable to verify if the Family Practice is in compliance with period of performance. Questioned costs: Unknown Context: During our review expenditures for period of performance we noted expenditures were not supported by adequate records and documentation to facilitate testing. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to identify expenses and the date incurred are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of Family Practice. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 302660

Finding 392308 (2021-004)

Significant Deficiency 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Cash Management Internal Control / Segregation of Duties Reporting

2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is ...

2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure documentation and records are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls.. Furthermore, a controller has been hired to prepare the reports and oversee cash management activities. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: March 11, 2024

View Audit 302660

Finding 392307 (2021-003)

Material Weakness 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...

2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024

View Audit 302660

Finding 392306 (2021-001)

Material Weakness 2021

St. John's Lutheran Home of Albert Lea

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.

View Audit 302650

Finding 392304 (2021-001)

None 2021

Covenant Health and Community Services, Inc.

FL

Reporting Matching / Level of Effort / Earmarking

We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further a...

We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further action should be needed.

View Audit 302628

Finding 392284 (2021-002)

None 2021

Columbia County Housing Corperation-Dba Community Strategies Group

PA

Reporting

CSG will ensure appropriate staff have adequate time to prepare for the audit and work with the audit firm to make sure the reporting package is submitted by the due dates on a go-forward basis.

View Audit 302555

Finding 392259 (2021-001)

Significant Deficiency 2021

First Person Care Clinic, Inc.

NV

Reporting

Finding 2021- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. The challenges we faced in meeting reporting deadlines were significantly compounded by the COVID-19 pandemic. Throughout 2021, our organization struggled to overcome ongoing obstacles due to a lack of pers...

Finding 2021- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. The challenges we faced in meeting reporting deadlines were significantly compounded by the COVID-19 pandemic. Throughout 2021, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.

View Audit 302530

Finding 392156 (2021-003)

Significant Deficiency 2021

Housing Authority of the City of Renton

WA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2021-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.

View Audit 302365

Finding 392121 (2021-002)

Material Weakness 2021

Pennsylvania Mountains Care Network

PA

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

Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts ...

Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts from its data supporting eligible expenditures. The adjustments needed within the PRF reports to correct the errors decreased year over year lost revenues from $21,664,944 to $11,771,346 and decreased eligible expenditures from $7,527,194 to $4,334,813, on total distributions of PRF funding of $14,972,846. In summary, the data supporting amounts for lost revenues and eligible expenses totals $16,104,159 on total distributions of PRF funding of $14,972,846 in this reporting period. Corrective Action Plan: System management agrees with the finding and has updated its lost revenue calculation. Management attempted to update lost revenue amounts with filing of its Period 4 reports; however, additional data entry errors were made. Management has worked extensively over the past two years to monitor the changing guidelines surrounding the various programs designed to respond to the COVID-19 pandemic. Management has furthered this effort by attending continuing professional education on this topic and reading available guidance to ensure that the final recordkeeping maintained by the System follows the guidance as established by HRSA.

View Audit 302290

Finding 392113 (2021-002)

Significant Deficiency 2021

Chesapeake Hospital Authority

VA

Subrecipient Monitoring Reporting § 200.512

2021-002 – Reporting – Submission of the Data Collection Form Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management acknowledges that the reporting package and data col...

2021-002 – Reporting – Submission of the Data Collection Form Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management acknowledges that the reporting package and data collection form for the year ended June 30, 2021, was not filed with the Federal Audit Clearinghouse on or before the extended deadline of September 30, 2022. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

View Audit 302275

Finding 392100 (2021-005)

Material Weakness 2021

Avita Health System

OH

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost reve...

Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost revenues were reported on the first period portal submission for Galion Community Hospital, another hospital of the Avita Health System. Planned Corrective Action: The portal submission could not be modified by the time we identified the reporting issue. As such, no corrective report was completed, however management will implement procedures to ensure reporting requirements are adequately reviewed for all federal funding. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024

View Audit 302244

Finding 392099 (2021-004)

Material Weakness 2021

Avita Health System

OH

Reporting Subrecipient Monitoring Material Weakness

Finding Number: 2021-004 Condition: The information entered into the period one HHS portal submission for Galion Community Hospital was not adequately supported or reviewed in accordance with the terms and conditions of the PRF funding and the Notice. Planned Corrective Action: The System utilized l...

Finding Number: 2021-004 Condition: The information entered into the period one HHS portal submission for Galion Community Hospital was not adequately supported or reviewed in accordance with the terms and conditions of the PRF funding and the Notice. Planned Corrective Action: The System utilized lost revenue to support expenditures recognized on the Schedule. For future grant funds received, management will adequately review terms and conditions of the funding received and ensure allowable expense are properly supported before completing the required reports. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024

View Audit 302244

Finding 392031 (2021-001)

Material Weakness 2021

Kalamazoo Loaves & Fishes Inc.

MI

Reporting

The Organization has established internal guidelines for identifying future Single Audit requirements and for contracting with an independent audit firm when required. Additionally, as evidenced by the filing of this report, the Organization has hired an independent audit firm to perform the audit f...

The Organization has established internal guidelines for identifying future Single Audit requirements and for contracting with an independent audit firm when required. Additionally, as evidenced by the filing of this report, the Organization has hired an independent audit firm to perform the audit for each of the years ended June 30, 2021 and 2020.

View Audit 302160

Finding 390821 (2021-001)

Significant Deficiency 2021

Brush Hill Development Corporation

MA

HUD Housing Programs Material Weakness Reporting

The audited financial statements have been filed with HUD via its REAC system. If thereare any questions regarding this plan, please call Yulia Garcia, Controller, at 508-778-5040.

View Audit 301537

Finding 390797 (2021-005)

None 2021

Helping Hand House

WA

Reporting § 200.512

1. In process of getting caught up on prior year audits will result in timely submission of data collection form going forward.

View Audit 301528

Finding 390795 (2021-003)

Material Weakness 2021

Helping Hand House

WA

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

1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.

View Audit 301528

Finding 389451 (2021-002)

Material Weakness 2021

Maryland Network Against Domestic Violence, INC

MD

Subrecipient Monitoring Material Weakness Reporting

2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarte...

2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarterly financial and performance reports are due within thirty calendar days from the end of each quarter. Annual financial and performance reports are due within 90 calendar days from the end of each grant year. During our testing, we noted nine reports that were submitted after the deadline. We consider this to be an instance of noncompliance and a material weakness in internal control over compliance for the reporting requirement. Statement of Concurrence or Nonconcurrence The Maryland Network Against Domestic Violence concurs with this finding. Corrective Action MNADV continued to experience significant transitions during FY21. FY21 was the first full fiscal year for the new Executive Director and a new finance manager was hired at the beginning of FY21. These senior leadership transitions were marked by a learning curve for both the Executive Director and Finance Manager who had to learn the reporting processes and online systems for each of the different grants which included federal, state and private reporting systems. Also of note was a lack of completed audits for FY19 and FY20, which meant that substantial work had to be completed to ensure that what was reported for each grant was indeed accurate. All of these factors contributed to reports being late and none of these factors are still at play. The current Executive Director and Finance Manager are now familiar with all reporting systems. All login and secondary authentication methods have been properly set up and are functioning as desired. Internal processes for collecting grant data and reporting out this data have been established.

View Audit 300405

Finding 387479 (2021-006)

Material Weakness 2021

Atoka County Healthcare Authority

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...

Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) 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: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022

View Audit 299648

Finding 387478 (2021-005)

Material Weakness 2021

Atoka County Healthcare Authority

OK

Reporting Material Weakness

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP pre...

Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP prepared the schedule of expenditures of federal awards (schedule) and accompanying notes to the schedule. Corrective Action Plan: Due to cost considerations, we will continue to have our auditor prepare our schedule and accompanying notes to the schedule. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: Ongoing.

View Audit 299648

Finding 386978 (2021-004)

Material Weakness 2021

Healthsource Saginaw, Inc.

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking

Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thorough...

Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 299334

Finding 386977 (2021-003)

Material Weakness 2021

Healthsource Saginaw, Inc.

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...

Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024

View Audit 299334

Finding 386902 (2021-005)

Significant Deficiency 2021

Canoncito Band of Navajos Health Center, Inc.

NM

Reporting

2021-005 – Reporting Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately complete the annual narrative reports for all fiscal years through September 30, 2023. • CBNHC will immediately complete the SF-425 financial reports for all fiscal years through ...

2021-005 – Reporting Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately complete the annual narrative reports for all fiscal years through September 30, 2023. • CBNHC will immediately complete the SF-425 financial reports for all fiscal years through September 30, 2023, and thereafter, every quarter through the current fiscal year. • CBNHC will actively communicate its status with the IHS Area Office regarding its progress towards the required deliverables. • CBNHC will implement an executive leadership team who are collectively responsible for assuring regulatory compliance for the entity, which will be achieved through the timely sharing of important information. • CBNHC’s Board of Directors will serve as governance over these requirements. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring that the annual narrative reports are submitted to IHS according to the AFA. In addition, the CEO will initiate monthly progress meetings with IHS. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring that the SF-425 financial reports are submitted to IHS according to the AFA. • Chief Executive Officer (Derrick Watchman), Chief Medical Officer (Sheryl O’Shea MD), Chief Operations Officer (Volelle Zamora), Executive Administrative Assistant (Ophelia Mace), and Human Resource Director (Christina Chavez) – Will serve as the CBNHC executive leadership team and are collectively responsible for assuring that the required reporting and other compliance are achieved. • Board of Directors (Kimberly Bruce, Harrison Platero, Lester Secatero) – Are responsible for CBNHC’s governance and will monitor required completion of reporting. Completion Date: The annual narrative reports for fiscal years 2021, 2022, and 2023 were completed as of December 31, 2023. The SF-425 reports will be completed and submitted to IHS by March 31, 2024. CBNHC is conducting monthly progress meetings with IHS regarding its requirements for financial reporting. CBNHC has implemented an executive leadership team, and they meet regularly, to share information and establish timelines for the completion and submission of its required reporting.

View Audit 299210

Finding 386898 (2021-004)

Material Weakness 2021

Canoncito Band of Navajos Health Center, Inc.

NM

Reporting § 200.512

2021-004 – Late Audit Report Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will continue in its recruiting and will hire the various accounting positions as defined in the corrective action plan for finding 2021-001. • CBNHC will implement the corrective actions...

2021-004 – Late Audit Report Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will continue in its recruiting and will hire the various accounting positions as defined in the corrective action plan for finding 2021-001. • CBNHC will implement the corrective actions described in the corrective action plan for finding 2021-001 to assure compliance with its regulatory requirement for completing its timely audits. • In the event that the CBNHC experiences changes in its staffing levels again, it will actively seek interim support through an accounting consultant in order to maintain its accounting records. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring the scope of work as defined in CBNHC’s Annual Funding Agreement (AFA) with the Indian Health Service (IHS) is administered accordingly. • Human Resource Director (Christina Chavez) – Will participate by actively recruiting for CBNHC’s vacant positions within the hiring requirements defined by the Navajo Nation. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring the timely completion of the CBNHC’s annual financial audits in accordance with the requirements defined by the Single Audit Act (2 CFR Part 200.512). Completion Date: June 30, 2024. CBNHC will be back on track with additional accounting support and expects to have its audit reports completed on time for fiscal year 2023.

View Audit 299210

Corrective Action Plans

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