Corrective Action Plans

Finding 31786 (2022-001)

Significant Deficiency 2022

CA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Finding 2022-001 Condition The change in status for two of three students tested were not reported to the National Student Loan Data System (NSLDS) within thirty days or included in a response to a roster file within sixty days. However, the students were ultimately reported to the NSLDS. Corrective...

Finding 2022-001 Condition The change in status for two of three students tested were not reported to the National Student Loan Data System (NSLDS) within thirty days or included in a response to a roster file within sixty days. However, the students were ultimately reported to the NSLDS. Corrective Action Plan During AY 2021-22, Fall 2021 and Spring 2022 graduates were mis-reported to Clearinghouse and NSLDS as `Withdrawn? instead of `Graduated?. Their final enrollment dates were reported correctly. A software update in our SIS now clearly flags graduates correctly. This update was in place in time for Fall 2022 graduates to be reported within the permitted time frame. This information was submitted to Clearinghouse on 12/6/22 and to NSLDS on 1/18/23. Going forward, after graduate data to Clearinghouse is submitted through our SIS the Registrar will double-check the NSLDS database to confirm it reflects the same information. In addition (and in broader terms) the Registrar will review available online enrollment reporting training modules provided by both FSA and Clearinghouse. Name(s) of Contact Person(s) Responsible for Corrective Action: John G M Seal Anticipated Completion Date: Software update was installed on 11/21/2022. Other corrective actions will be ongoing. John G M Seal, Consortial Registrar

View Audit 26568

Finding 31713 (2022-002)

Significant Deficiency 2022

La Habra City School District

CA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Corrective Action Plan and Views of Responsible Officials The District will review and verify with District auditors all funding programs to verify allowable indirect costs.

View Audit 31420 Questioned Costs: $1

Finding 31712 (2022-001)

Significant Deficiency 2022

La Habra City School District

CA

Significant Deficiency Special Tests & Provisions

Corrective Action Plan and Views of Responsible Officials The District will document all correspondence with private schools who may benefit from Federal funding based on student population. This will include documented calls with dates, times, and private school staff names.

View Audit 31420

Finding 31705 (2022-002)

Significant Deficiency 2022

Lakeview College of Nursing

IL

Student Financial Aid Subrecipient Monitoring Reporting

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-002 Student Financial Assistance Program - Assistance Listing No. 84.063 and 84.268 Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting, including additional monitori...

FINDINGS-FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-002 Student Financial Assistance Program - Assistance Listing No. 84.063 and 84.268 Recommendation: We recommend that the College enhance its policies and procedures regarding enrollment reporting, including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: [Describe action planned or taken]. ? Additional reports will be reviewed before submitting the first-of-term information to the National Student Clearinghouse. ? Future semesters begin and end dates are created three years in advance to avoid date changes. ? The Registrar will complete a monthly review of students in the NSLDS system to ensure enrollment begin and end dates are accurate according to College Academic Calendar and clearinghouse submission. Name(s) of the contact person(s) responsible for corrective action: ? Connie Young, Director of Enrollment/Registrar Planned completion date for a corrective action plan: ? August 1, 2023. If the U.S. Department of Education has questions regarding this schedule, please call Sheila Mingee at 217-709-0923.

View Audit 26744

Finding 31683 (2022-003)

Significant Deficiency 2022

Universidad Carlos Albizu, Inc.

PR

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Condition found During our audit procedures on the expenses of `?Promoting Safe and Stable Families - Family First Prevention Act Transition Grant? (Family First), we examined forty-three (43) transactions. We found that one purchase requisition was created after the expense was incurred. Institut...

Condition found During our audit procedures on the expenses of `?Promoting Safe and Stable Families - Family First Prevention Act Transition Grant? (Family First), we examined forty-three (43) transactions. We found that one purchase requisition was created after the expense was incurred. Institution Response The University agrees with the finding. Corrective Action Plan This finding is for a transaction that occurred before the corrective action plan implemented by the University to address this issue. The Institute provided training to their staff to ensure that all disbursements included all the required documentation in accordance with the University's policy. This training was carried out for all personnel involved in the purchasing process. In addition, the University hired a public accounting firm to carry out an internal audit process which included actions that were aimed at resolving this finding. No cases of this nature were identified after the corrective action plan was implemented. Name (s) of the Contact Person (s) Responsible for Corrective Action Ramon L. Menendez, Chief Financial Officer Anticipated Completion Date Completed as of June 30, 2022.

View Audit 34495

Finding 31657 (2022-008)

Significant Deficiency 2022

Housing for the Multi-Handicapped Blind

NY

HUD Housing Programs Reporting Significant Deficiency

Reporting views of responsible officials and planned corrective actions Management put in place an electronic work order system that keeps track of the work orders for the property and has put controls in place to actively monitor the system to ensure appropriate repairs are being completed in a tim...

Reporting views of responsible officials and planned corrective actions Management put in place an electronic work order system that keeps track of the work orders for the property and has put controls in place to actively monitor the system to ensure appropriate repairs are being completed in a timely manner.

View Audit 27899

Finding 31656 (2022-007)

Significant Deficiency 2022

Housing for the Multi-Handicapped Blind

NY

HUD Housing Programs Reporting Significant Deficiency

Reporting views of responsible officials and planned corrective actions Management will put in place procedures to ensure verification of tenant assets is done during recertification.

View Audit 27899

Finding 31646 (2022-007)

Significant Deficiency 2022

City of Baker City, Oregon

OR

Allowable Costs / Cost Principles Reporting Significant Deficiency

Management will report only expended grant funds on all future reporting. Furthermore, management is pursuing the possibility of amending the initial filing report of April 2022 for Coronavirus State and Local Fiscal Recovery Funds (ARPA) CFDA #21.027. Baker City has an upcoming second reporting to ...

Management will report only expended grant funds on all future reporting. Furthermore, management is pursuing the possibility of amending the initial filing report of April 2022 for Coronavirus State and Local Fiscal Recovery Funds (ARPA) CFDA #21.027. Baker City has an upcoming second reporting to CSLFRF as of April 30, 2023, and will report only expended funds at that time.

View Audit 28409

Finding 31571 (2022-003)

Significant Deficiency 2022

West Virginia State University Research and Development Corporation

WV

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.77

Research and Development Cluster ? Assistance Listing No. 10.216 Recommendation: We recommend that the Corporation review their period of performance process to ensure that costs that are charged against the grants are within the period of performance. Explanation of disagreement with audit finding:...

Research and Development Cluster ? Assistance Listing No. 10.216 Recommendation: We recommend that the Corporation review their period of performance process to ensure that costs that are charged against the grants are within the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The budget office will review final reports with the OSP post award area to ensure final narratives, final financial reports and the final draw of funds are correct and fall within the grant performance period. Name of the contact person responsible for corrective action: Kim Duff, Executive Director Planned completion date for corrective action plan: March 2023

View Audit 35914

Finding 31570 (2022-002)

Significant Deficiency 2022

West Virginia State University Research and Development Corporation

WV

Questioned Costs Reporting Significant Deficiency

Research and Development Cluster ? Assistance Listing Nos. 10.216, 10.310, 47.083 Recommendation: We recommend that the Corporation review their time and effort after the- fact reporting policy and ensure it is followed throughout the life of federal grants. Explanation of disagreement with audit fi...

Research and Development Cluster ? Assistance Listing Nos. 10.216, 10.310, 47.083 Recommendation: We recommend that the Corporation review their time and effort after the- fact reporting policy and ensure it is followed throughout the life of federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We have reviewed the OSP Time and Effort policy and reinstated post award procedures to review terms and conditions of each grant and complete the post award responsibility summary form with the PI?s. After the post award process, the PI will confirm time and effort on a quarterly basis (at a minimum) with OSP. OSP will forward the information to the budget office and the corresponding payroll changes will be completed and reviewed by the budget office and executive director. Name of the contact person responsible for corrective action: Kim Duff, Executive Director Planned completion date for corrective action plan: March 2023

View Audit 35914 Questioned Costs: $1

Finding 31566 (2022-005)

Significant Deficiency 2022

Feed the Children, Inc.

OK

Reporting Period of Performance Significant Deficiency § 200.502

Finding Number: 2022-005 Condition: The schedule of expenditures of federal awards (SEFA) for the year ended June 30, 2022 includes expenditures incurred during the prior fiscal year. Planned Corrective Action: The Organization acknowledges this finding. Going forward the Organization will implem...

Finding Number: 2022-005 Condition: The schedule of expenditures of federal awards (SEFA) for the year ended June 30, 2022 includes expenditures incurred during the prior fiscal year. Planned Corrective Action: The Organization acknowledges this finding. Going forward the Organization will implement a review process of the Schedule of Expenditures of Federal Awards. Contact person responsible for corrective action: Bregeita Jefferson, President of FEED International Anticipated Completion Date: January 31, 2023

View Audit 32944

Finding 31527 (2022-002)

Significant Deficiency 2022

City of Austin

TX

Cash Management Reporting Significant Deficiency

Finding 2022-002: Control Finding?Significant Deficiency?Immunization Outreach?Reporting Contact Person? Adrienne Sturrup, Austin Public Health Director Management Response? Austin Public Health (APH) identified the reporting discrepancy in August 2022 and quickly implemented tighter controls to tra...

Finding 2022-002: Control Finding?Significant Deficiency?Immunization Outreach?Reporting Contact Person? Adrienne Sturrup, Austin Public Health Director Management Response? Austin Public Health (APH) identified the reporting discrepancy in August 2022 and quickly implemented tighter controls to track the timely submission of the Financial Status Reports (FSRs). The new process was fully implemented on 10/1/2022. APH experienced a large increase in grants from multiple sources related to COVID-19. APH also experienced a complete staff turnover and the addition of two accountant positions for grant billing. The new controls are as follows: APH has implemented a monthly checklist for all Accountants to utilize during monthly grant billings. This checklist contains all monthly responsibilities, including each grant requiring FSR, B-13, supplemental forms, invoices/voucher, and any other items required to be submitted to the grantor. This checklist is submitted to the Accounting Manager to review with each grant monthly billing. 1. Each FSR due date is now recorded on the cover sheet check list of each monthly billing. 2. The FSR is submitted to the Accounting Manager with the monthly billing. 3. The grant does not get approved unless requirements 1 and 2 are met. 4. The Accounting Manager then sends the FSR to the Grantor and the accountant to record.

View Audit 35930

Finding 31500 (2022-002)

Significant Deficiency 2022

Midland Area Agency on Aging

NE

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

View of Responsible Officials and Planned Corrective Actions: The Organization is committed to properly tracking and allocating Federal expenditures. The Organization has created adequate internal control processes to ensure general and administrative time is allocated based on a monthly average o...

View of Responsible Officials and Planned Corrective Actions: The Organization is committed to properly tracking and allocating Federal expenditures. The Organization has created adequate internal control processes to ensure general and administrative time is allocated based on a monthly average of allocated hours by program.

View Audit 26515

Finding 31480 (2022-001)

Significant Deficiency 2022

Treasure Valley Community College

OR

Student Financial Aid Reporting Subrecipient Monitoring

FINDINGS ? FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 ? Student Financial Assistance Cluster ? CFDA No. 84.268, 84.063 Special Tests and Provisions ? Enrollment Reporting ? Significant Deficiency in Internal Control over Compliance Recommendation: The auditors recommend the ...

FINDINGS ? FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 ? Student Financial Assistance Cluster ? CFDA No. 84.268, 84.063 Special Tests and Provisions ? Enrollment Reporting ? Significant Deficiency in Internal Control over Compliance Recommendation: The auditors recommend the College follow and enhance existing policies to ensure all student changes in status are identified timely and submitted accurately within the required time frame. The auditors also recommend a review of roles and responsibilities surrounding this process be evaluated and, if deemed necessary, revised. Lastly, the auditors recommend the College establish a formal internal monitoring control whereby a designated individual with NSLDS access, on a sample basis, spot checks the status updates on NSLDS so to internally audit the NSC submissions. Action taken: The College concurs with this finding. The College has made progress in the restructuring of positions and duties in the financial aid and registrar offices within the Student Services area. This will assist in improving coordination between those parties involved in degree and enrollment reporting as well as contributing to the streamlining of the reporting and correction process to eliminate errors and findings. Each of these departments will coordinate training and standard operating procedures for timely and accurate reporting to the appropriate entities. The College has intentions of fulfilling the following actions to make continued progress toward compliance under this finding: ? Hire Enterprise Network Position in Student Services to assist with reporting and student information services. ? Provide ongoing and intensive trainings for new Financial Adi Staff, new Registrar and the Enterprise Network position, once filled. ? Collaborate with appropriate colleagues in Oregon using similar Student Information Systems that are currently addressing or have previously addressed enrollment reporting concerns. ? Utilize an external review service of Financial Aid software for recommendations on improvements. ? Identify college policy to address and draft to support accurate enrollment reporting. Name of Responsible Party: Diahann Derrick, Director of Financial Aid Anticipated completion date: June 30, 2023

View Audit 25834

Finding 31476 (2022-001)

None 2022

City of Nome, Alaska

AK

Reporting Significant Deficiency § 200.512

Finding 2022-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Nickie Crowe, Finance Director Corrective Action Plan: The City of Nome will communicate with Nome Joint Utility System (NJUS) by July 1 of each year requesting their confirmation on the schedule ...

Finding 2022-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Nickie Crowe, Finance Director Corrective Action Plan: The City of Nome will communicate with Nome Joint Utility System (NJUS) by July 1 of each year requesting their confirmation on the schedule for the completion of NJUS? audited financial statements not later than November 30. The City of Nome and NJUS will communicate monthly on the status of the NJUS Audited Financials until the target date of November 30 of each year is met. If NJUS fails to communicate, the Nome Common Council will be notified immediately so that new action can be taken to ensure the City of Nome is compliant on future audits. Proposed Completion Date: November 30, 2023

View Audit 26921

Finding 31412 (2022-001)

Significant Deficiency 2022

McCormick Commission of Public Works

SC

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

SIFNIFICANT DEFICIENCY: 2022-001 SEGREGATION OF DUTIES: NAME OF CONTACT PERSON: CHERYL DANIELS, GENERAL MANAGER. CORRECTIVE ACTION: THE DUTIES WILL BE SEGREGATED AS MUCH AS POSSIBLE AND THE COMMISSIONERS WILL REMAIN INVOLVED IN THE FINANCIAL AFFAIRS OF THE COMMISSION TO PROVIDE OVERSIGHT AND INDEPEN...

SIFNIFICANT DEFICIENCY: 2022-001 SEGREGATION OF DUTIES: NAME OF CONTACT PERSON: CHERYL DANIELS, GENERAL MANAGER. CORRECTIVE ACTION: THE DUTIES WILL BE SEGREGATED AS MUCH AS POSSIBLE AND THE COMMISSIONERS WILL REMAIN INVOLVED IN THE FINANCIAL AFFAIRS OF THE COMMISSION TO PROVIDE OVERSIGHT AND INDEPENDENT REVIEW FUNCTIONS. PROPOSED COMPLETION DATE: MANAGEMENT WILL IMPLEMENT THE ABOVE ACTION IMMEDIATELY.

View Audit 35901

Finding 31343 (2022-001)

Significant Deficiency 2022

Civil Air Patrol

AL

Significant Deficiency Equipment & Real Property Management

We concur with the finding and have implemented procedures to address all issues. Approximately 90% of the items listed in ORMS that were found to be missing in-service dates were not fixed assets. More than half of the items were acquired more than 5 years ago. In-service dates have been added in O...

We concur with the finding and have implemented procedures to address all issues. Approximately 90% of the items listed in ORMS that were found to be missing in-service dates were not fixed assets. More than half of the items were acquired more than 5 years ago. In-service dates have been added in ORMS for all items which did not have one. This was implemented April 2023. The in-service date in ORMS was an optional field which was often left blank since an acquisition date was usually entered and the two are often the same. The field is now required and will be reviewed at least quarterly to ensure no items have blank fields. In-service dates for all fixed assets will be verified and matched to the accounting system during the fixed asset reconciliation each month. This will be implemented May 2023. It is common for some equipment to be removed from aircraft when the aircraft is sold. Those items generally remain in fixed assets for future use. CAP Financial Management (FM) requests this information from CAP Logistics (LG) and that process has worked well in the past. However, in fiscal year 2022, four items which were retained from disposed aircraft were inadvertently disposed of in the accounting software. This was due to a miscommunication between FM and LG. We will begin verifying the items that are retained by checking ORMS and including multiple LG staff members on our communications. This will be implemented May 2023. CAP uses contra accounts to offset expenses when items are capitalized. Items are often purchased with various funds. Our entries are created manually and can consist of hundreds of lines. This can sometimes result in errors when the additions are posted to the contra accounts. We had some assets which were funded with appropriated funds, but the contra entry was posted to a different fund causing the funds to be out of balance. A correction was posted when the error was found. We will start reconciling contra accounts by fund during the monthly fixed asset reconciliation process. This will be implemented May 2023.

View Audit 33790

Finding 31320 (2022-002)

Significant Deficiency 2022

Swift County-Benson Hospital

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 4 TIN #411670269 Federal Financial Assistance Listing: #93.498 Finding...

Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 4 TIN #411670269 Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization?s expense workbook and special reports submitted to the Department of Health and Human Services for Period 4 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Andrea Smart, Vice President of Financial Services and Treasury. Corrective Action Plan: Management will implement a control process which includes a secondary review and approval of any future summarized final expenditure listing used to claim the allowable costs under the federal program. Anticipated Completion Date: September 26, 2023.

View Audit 26844

Finding 31315 (2022-001)

Significant Deficiency 2022

Lincoln Land Community College

IL

Procurement, Suspension & Debarment Significant Deficiency

Action taken in response to finding: Procedures are in place, but due to changes in purchasing personnel, the process to verify entities during the fiscal year were not operating effectively. The College will formalize and ensure the consistent operation of a vendor verification process for its cove...

Action taken in response to finding: Procedures are in place, but due to changes in purchasing personnel, the process to verify entities during the fiscal year were not operating effectively. The College will formalize and ensure the consistent operation of a vendor verification process for its covered transactions.

View Audit 30744

Finding 31267 (2022-004)

Significant Deficiency 2022

Ravenwood Mental Health Center, INC

OH

Questioned Costs Cash Management Significant Deficiency § 200.516

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made...

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made changes in the accounting department during the past year to improve the overall functionality. Since we tripled our amount of grants, it was necessary to increase the accounting staff to maintain them, as well as increase overall efficiencies. We now have a staff of 4 accountants, as well as a new CFO with nonprofit/grant experience. The late filling of vacant positions delayed some of our internal processes during their training. We added monthly meetings with internal staff to make sure we have a good communication flow and appropriate documentation for new and existing grants which are monitored monthly Anticipated Completion Date: June 30, 2023

View Audit 31455 Questioned Costs: $1

Finding 31264 (2022-003)

Significant Deficiency 2022

Stockton Port District

CA

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

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficien...

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficiency, Instance of Non-compliance Views of Responsible Officials: We concur. Corrective Action Plan: Update reporting procedures to include documentation of the individual that prepared the semi-annual performance reports Responsible Individual(s): Steve Larson, Grants Manager Jeff Wingfield, Deputy Port Director, Regulatory & Public Affairs Anticipated Completion Date: Procedures to be updated by March 31, 2023.

View Audit 30245

Finding 31263 (2022-002)

Significant Deficiency 2022

Stockton Port District

CA

Procurement, Suspension & Debarment Significant Deficiency § 200.327

Finding 2022-002 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Procurement, Suspension and Debarment Type of F...

Finding 2022-002 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Procurement, Suspension and Debarment Type of Finding: Significant Deficiency, Instance of Non-compliance Views of Responsible Officials: We concur. Corrective Action Plan: Review and update the District?s Procurement procedures to ensure that all required provisions are included in its contracts. Responsible Individual(s): Juan Villanueva, Director of Facilities and Procurement Anticipated Completion Date: Initial update to procurement procedures to be completed by March 31, 2023 with periodic reviews.

View Audit 30245

Finding 31249 (2022-003)

Significant Deficiency 2022

Newbury Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing st...

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing staff members allocation of time to a prope1iy will continue to be implemented and refined. Anticipated Completion: December 31, 2022 ( ongoing) Contact: Jill Lesmerises, Chief Fiscal Officer Michael Tabory, Chief Operating Officer

View Audit 26553

Finding 31233 (2022-001)

Significant Deficiency 2022

Valley Crossroads, Inc.

UT

HUD Housing Programs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

1. Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding. b. Action(s) Taken or Planned on the Finding The Corporation will take the following steps: (1) Develop a plan to address staffing and turnover issues: we will work with the HR department to d...

1. Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding. b. Action(s) Taken or Planned on the Finding The Corporation will take the following steps: (1) Develop a plan to address staffing and turnover issues: we will work with the HR department to develop a plan to address staffing and turnover issues. This may include conducting a salary and benefits review to ensure that we are competitive in the market, providing opportunities for professional development and growth, and creating a positive work environment; (2) Prioritize the completion of annual recertifications: we will work with the team to prioritize the completion of annual recertifications. This will involve allocating additional resources, if necessary, and bringing in outside help to complete the recertifications on time; (3) Develop a monitoring plan: we will develop a monitoring plan to ensure that annual reexaminations are completed on time. This will include regular checks of tenant files and random sampling to ensure compliance with the regulations; (4) Train staff: we will ensure that all staff involved in the annual reexamination process are trained on the importance of completing them on time, the potential consequences of failing to do so, and the regulations and policies related to annual reexaminations; and (5) Implement a tracking system: we will implement a tracking system to ensure that annual reexaminations are completed on time. The system will include reminders for staff and tenants and a process for tracking the progress of each recertification.

View Audit 36537

Finding 31232 (2022-002)

Significant Deficiency 2022

Central Peninsula General Hospital, Inc.

AK

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-002: Allowable Costs- Noncompliance and Significant Deficiency in Internal Control over Compliance. Program : Emergency Grants to Address Mental and Substance Use Disorders During Covid -19, Assistance Listing Number: 93.665. Planned Corrective Action Plan : To eliminate human error...

Finding 2022-002: Allowable Costs- Noncompliance and Significant Deficiency in Internal Control over Compliance. Program : Emergency Grants to Address Mental and Substance Use Disorders During Covid -19, Assistance Listing Number: 93.665. Planned Corrective Action Plan : To eliminate human error due to manual keying, we are now running a canned report out of the payroll system which displays employee name, employee number, and current pay rate in an Excel file . This report is emailed to the Behavioral Health supervisor who prepares the payroll portion for each grant. Completion Date : Already implemented. Contact: Nicki McKinney, Controller (nmckinney@cpgh .org)

View Audit 34916

Corrective Action Plans

Filters