Corrective Action Plans

Finding 12890 (2022-002)

Significant Deficiency 2022

Cambridge Community Unit School District No. 227

IL

Internal Control / Segregation of Duties Cash Management Eligibility

Condition: Monthly Claim for Reimbursement included second meal claims in excess of two percent of the number of first meals served to children for each meal type. Plan: Implement additional procedures to ensure t...

Condition: Monthly Claim for Reimbursement included second meal claims in excess of two percent of the number of first meals served to children for each meal type. Plan: Implement additional procedures to ensure the accuracy of meal counts prior to the submission of the monthly Claim for Reimbursement such as but not limited to training and conferences. Additionally, the District should contact the Illinois State Board of Education for further recommendation on this finding. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Thomas Akers, Superintendent Management's response: There is no disagreement with this finding and procedures will be implemented. The District will contact the Illinois State Board of Education for further recommendation.

View Audit 17428

Finding 12889 (2022-003)

Significant Deficiency 2022

Cambridge Community Unit School District No. 227

IL

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Significant Deficiency § 200.501 § 200.516

Condition: The District overstated expenditures on the ESSER I June 30, 2021 expenditure report. Plan: Grant expenditures should be reviewed and reconciled back to the accounting records prior to submitting final reports; ISBE grants division should be contacted regard...

Condition: The District overstated expenditures on the ESSER I June 30, 2021 expenditure report. Plan: Grant expenditures should be reviewed and reconciled back to the accounting records prior to submitting final reports; ISBE grants division should be contacted regarding this discrepancy. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Thomas Akers, Superintendent Management's response: The District agrees that the expenditures claimed on the June 30, 2021 expenditure report was overstated by $10,678 and in the future will review and reconcile the expenditure reports to the accounting records before submitting to ISBE.

View Audit 17428

Finding 12882 (2022-001)

Significant Deficiency 2022

Capitol Region Education Council

CT

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

Government Officials Capitol Region Education Council respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 202 - June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numb...

Government Officials Capitol Region Education Council respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 202 - June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no findings in the current year that require a corrective action plan. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS United States Department of Education 2022-001 Title I Grants to Local Educational Agencies ? Assistance Listing No. 84.010 Recommendation: We recommend that the policies and procedures related to approval process be followed to ensure that all exit forms have the proper approvals for removing a student from the adjusted regulatory cohort. Explanation of disagreement with audit finding: To remove a student from the cohort, a school or LEA must confirm, in writing, that the student transferred out, emigrated to another country, transferred to a prison or juvenile facility, or is deceased. To confirm that a student transferred out, the school or LEA must have official written documentation that the student enrolled in another school or in an educational program that culminated in the award of a regular high school diploma. From the 40 selections tested, there was 1 student for which no written documentation was maintained including parent or guardian signature to support that the student either transferred out, emigrated to another country, transferred to a prison or juvenile facility, or was deceased. Action taken in response to finding: CREC has considered the recommendations and will organize training of school and staff who work with student records that will include instruction on student withdrawal procedures. SDE and CREC accepts the request for a transcript from the receiving district as documentation for the withdrawal of the student from a CREC school. Name(s) of the contact person(s) responsible for corrective action: Jeff Ivory, Comptroller, (860) 524-4068 Planned completion date for corrective action plan: June 30, 2023

View Audit 17158

Finding 12872 (2022-001)

None 2022

Homeward Pikes Peak

CO

HUD Housing Programs Significant Deficiency

Homeward Pikes Peak respectfully submits the following corrective action plan for the year ended December 31, 2022. Steve Mack Director of Finance SECTION III ? FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Department of Housing and Urban Development 2022-001 ? Continuum of Care Program ? CFDA No. 14....

Homeward Pikes Peak respectfully submits the following corrective action plan for the year ended December 31, 2022. Steve Mack Director of Finance SECTION III ? FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Department of Housing and Urban Development 2022-001 ? Continuum of Care Program ? CFDA No. 14.267 Criteria: Where grants are used to pay rent for individual housing units, the rent paid must be reasonable in relation to rents being charged for comparable units taking into account relevant features. In addition, the rents may not exceed rents currently being charged by the same owner for comparable unassisted units, and the portion of rents paid with grant funds may not exceed HUDdetermined fair market rents. Condition: A rental rate comparison to HUD published fair market rents was not performed for one tenant out of the 37 cases selected for testing, and there was no manager approval on the rental rate comparison to HUD published fair market rents for two other tenants out of the 37 cases selected for testing. View of Responsible Official and Planned Corrective Action: This deficiency has been fully addressed. Policies have been implemented by the Organization to ensure rental rates are compared to HUD published fair market rents for all tenants and that managers document their review.

View Audit 17206

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 12854 (2022-001)

Significant Deficiency 2022

Elm Hill Water District

MA

Internal Control / Segregation of Duties Significant Deficiency

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 17759

Finding 12771 (2022-004)

Significant Deficiency 2022

Charles County Public Schools

MD

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period o...

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Fiscal Services will improve internal controls over the procedures that ensure expenditures to a program are incurred within an award?s allowable period of performance. During the year-end close out process, the Lead Restricted Funds Accountant will review the close out of all restricted funds against the grant periods. If expenditures are inadvertently incurred outside of the grant period, the expenditures will be reclassified to an existing like grant if allowable or to the operating budget. If the Lead Restricted Funds Accountant is unavailable or has closed out grants themselves, this review will be done by the Budget Manager. The school district will implement a new financial system in July 2023. The implementation of this new system will allow for more automated internal controls. Name(s) of the contact person(s) responsible for corrective action: Rosa Aquino and/or Sherri Fisher-Davis Planned completion date for corrective action plan: December 31, 2022

View Audit 17731

Finding 12720 (2022-006)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Significant Deficiency Internal Control / Segregation of Duties

Department of Veterans Affairs 2022-006 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: We recommend the Inner Voice review its policies and procedures at the conclusion of an award period and obtain authorization from the federal awarding agency for...

Department of Veterans Affairs 2022-006 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: We recommend the Inner Voice review its policies and procedures at the conclusion of an award period and obtain authorization from the federal awarding agency for costs incurred after the award period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Inner voice has approached VA Authority on this issue and they have no issue as this cost is immaterial. However, moving forward Inner voice will not allocate cost to the program and grant unless work is completed or approved by the funder in instances where the work cannot be completed during the program year. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: Effective immediately.

View Audit 17548

Finding 12719 (2022-005)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Significant Deficiency

2022-005 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: The Inner Voice should implement a procurement policy and procedure that includes the selection and documentation of procurement rationale, controls and oversight. This policy should be follow...

2022-005 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: The Inner Voice should implement a procurement policy and procedure that includes the selection and documentation of procurement rationale, controls and oversight. This policy should be followed for all procurement transactions and include compliance requirements UG ?200.318 general procurement standards, UG ?200.319 competition, and ?200.320 methods of procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policy is drafted and under discussion before bring this to the Board for a formal approval and its implementation. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: After the approval of the Board that is planned to be held during the month of March.

View Audit 17548

Finding 12718 (2022-004)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Allowable Costs / Cost Principles Significant Deficiency

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 12697 (2022-003)

Significant Deficiency 2022

Regional Transit Authority (a.r.t.)

IA

Significant Deficiency Internal Control / Segregation of Duties

SIGNIFICANT DEFICIENCY: 2022-003 In-Kind Procedures: Criteria ? The Authority is responsible for establishing and maintaining internal controls for recording in-kind revenues & expenses. Condition ? During the performance of our audit, it was determined that the review proced...

SIGNIFICANT DEFICIENCY: 2022-003 In-Kind Procedures: Criteria ? The Authority is responsible for establishing and maintaining internal controls for recording in-kind revenues & expenses. Condition ? During the performance of our audit, it was determined that the review procedures for in-kind revenues and expenses were not adequate for identifying if improper amounts were recorded. Cause ? The Authority has not designed adequate procedures for reviewing in-kind revenues and expenses. Effect ? As a result of these inadequate procedures, there is a higher threat that errors or improper amounts could be recorded as in-kind revenues and expenses. Recommendation ?The Authority should review and revise procedures to ensure in-kind revenues and expenses are being properly recorded and reviewed. Client?s Response ? We will review our current procedures to ensure in-kind revenues and expenses are properly reviewed and recorded in the financial statements in the future.

View Audit 18194

Finding 12668 (2022-002)

Significant Deficiency 2022

Center City Housing Corp.

MN

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

2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and ...

2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and is in the process of adopting these policies and procedures. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.

View Audit 18183

Finding 12634 (2022-011)

Significant Deficiency 2022

Barclay College

KS

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

SIGNIFICANT DEFICIENCY 2022-011 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Reporting Condition Evidence of the date that quarterly reports were uploaded to the College?s website were not saved, and during inquiry with key personnel, it was determined that not ...

SIGNIFICANT DEFICIENCY 2022-011 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Reporting Condition Evidence of the date that quarterly reports were uploaded to the College?s website were not saved, and during inquiry with key personnel, it was determined that not all of the reports were uploaded within 10 days following the quarter end. The reports later had to be amended to add required information and update expense amounts, and the changes were not conspicuously noted or dated. In addition, errors were noted within the annual report. Recommendation We recommend that the institution implement controls to ensure that reports are completed timely and accurately, and that evidence of submission or upload dates is saved. Actions Taken As of March 23, 2023, evidence of public posting dates will be saved during the publishing process. In addition, a reconciliation has been implemented in which an individual other than the preparer will review the report for accuracy prior to submission or publication.

View Audit 17529

Finding 12631 (2022-007)

Significant Deficiency 2022

Barclay College

KS

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct ...

SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct loan award amounts are reviewed for accuracy prior to making awards to students. Actions Taken As of March 23, 2023, the College has begun to implement a review of student awards that will include reviewing all aid and credits that the student is receiving and double checking NSLDS loan amount limits.

View Audit 17529

Finding 12628 (2022-006)

Significant Deficiency 2022

Barclay College

KS

Student Financial Aid Reporting Significant Deficiency

SIGNIFICANT DEFICIENCY 2022-006 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, it was discovered that COD reflected inaccurate disbursement amounts for two students. Recommendation We recommend that the institution review its reconciliation proce...

SIGNIFICANT DEFICIENCY 2022-006 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, it was discovered that COD reflected inaccurate disbursement amounts for two students. Recommendation We recommend that the institution review its reconciliation process and implement controls to ensure that COD records accurately reflect actual disbursements. In addition, we recommend that the institution implement a control to ensure that all completed verifications have been reported to COD. Actions Taken As of March 23, 2023, COD records have been updated for the two students in question. In addition, communication is ongoing with the College?s software provider in order to work towards a control that will ensure that this error does not occur again. Lastly, the College has implemented a review process to ensure that applicable students have completed their verification, and the third-party vendor who completes the verification process has been contacted about setting up a notification system to alert personnel when a student completes their verification.

View Audit 17529

Finding 12627 (2022-005)

Significant Deficiency 2022

Barclay College

KS

Student Financial Aid Eligibility Significant Deficiency

SIGNIFICANT DEFICIENCY 2022-005 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered one student was incorrectly awarded Pell, and two others did not receive Pell disbursements for both eligible semesters attended during the year. R...

SIGNIFICANT DEFICIENCY 2022-005 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered one student was incorrectly awarded Pell, and two others did not receive Pell disbursements for both eligible semesters attended during the year. Recommendation We recommend that the institution implement controls to ensure that all scheduled disbursements are ultimately posted. In addition, when calculating Pell awards, the Payment and Disbursement Schedule that matches the student?s enrollment status should be carefully selected and applied. Actions Taken As of March 23, 2023, the scheduled Pell awards for the two noted students have been posted and disbursed. In addition, an additional review step has been implemented to take place before any aid disbursements are made.

View Audit 17529

Finding 12623 (2022-003)

Significant Deficiency 2022

Barclay College

KS

Student Financial Aid Reporting Significant Deficiency

SIGNIFICANT DEFICIENCY 2022-003 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, items reported within the FISAP were found to be inaccurate or were unable to be substantiated due to a lack of supporting documentation. Recommendation We recommend that ...

SIGNIFICANT DEFICIENCY 2022-003 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, items reported within the FISAP were found to be inaccurate or were unable to be substantiated due to a lack of supporting documentation. Recommendation We recommend that all supporting documentation used in the preparation of the FISAP be saved in an easily identifiable location. Actions Taken As of March 23, 2023, all documents used in the preparation of the FISAP will be saved and filed in one location at the time of preparation.

View Audit 17529

Finding 12621 (2022-001)

Significant Deficiency 2022

Village Cooperative of Red Wing

MN

Internal Control / Segregation of Duties Significant Deficiency

Department of Housing and Urban Development: HUD project FHA #092-23267 Village Cooperative of Red Wing Federal ID# 20-2185423 The FASS system generated the following findings from its review of the September 30, 2022 financial statements. The results of the assessment are summarized below. The proj...

Department of Housing and Urban Development: HUD project FHA #092-23267 Village Cooperative of Red Wing Federal ID# 20-2185423 The FASS system generated the following findings from its review of the September 30, 2022 financial statements. The results of the assessment are summarized below. The project owner should provide their assigned HUD Project Manager a written response addressing each of the findings, and appropriate documentation (e.g. copies of cancelled checks, bank statements, etc.) to prove the finding has been resolved. Project Auditor Findings: The auditor reported the following findings: Compliance Oriented Findings. The Schedule of Findings and Questioned Costs by the auditor contained findings related to the following Auditor Indicator Codes: Finding Reference No. / Code - Finding Condition 2022-001 / S - Internal Control Deficiencies Corrective Action(s). For all audit findings that were unresolved as of the date of the audit report, the owner must provide their HUD Project Manager a written response and supporting documentation indicating the finding has been resolved. Corrective Action Plan: The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 17523

Finding 12620 (2022-001)

Significant Deficiency 2022

Canton City School District

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Finding Number Planned Corrective Action Anticipated Completion Date Responsible Contact Person 2022-001 Procedures will be reviewed over the payroll process to ensure after that documentation is maintained to support payment with federal funds. June 30, 2023 Jeff Gruber, Treasurer

View Audit 17509

Finding 12605 (2022-001)

Significant Deficiency 2022

City of Palmer, Alaska

AK

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

City of Palmer, Alaska Corrective Action Plan Year Ended December 31, 2022 Name of Contact Person: Gina Davis Finance Director 907-761-1314 Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance ? Reporting Corrective Action Implementation All grant reporting is t...

City of Palmer, Alaska Corrective Action Plan Year Ended December 31, 2022 Name of Contact Person: Gina Davis Finance Director 907-761-1314 Finding 2022-001 Significant Deficiency in Internal Control over Compliance, Noncompliance ? Reporting Corrective Action Implementation All grant reporting is to be reviewed for accuracy by the Finance Director or the Controller prior to submittal. Anticipated Completion Date We plan on having the CSLFRF report updated on the Treasury website by 12/31/2023.

View Audit 17489

Finding 12577 (2022-001)

Significant Deficiency 2022

Chisago County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Robert Benson Todd McMurray Corrective Action Planned: Chisago County will implement additional procedures to provide reasonable assurance that all...

Finding Number: 2022-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Robert Benson Todd McMurray Corrective Action Planned: Chisago County will implement additional procedures to provide reasonable assurance that all necessary documentation is properly inputted or updated in MAXIS. This will include internal staff training/updates at monthly unit meetings on the importance of accuracy in our case files. Our agency will also be implementing internal supervisory case reviews to ensure accuracy practices are being followed. Anticipated Completion Date: Our corrective action plan will be implemented immediately and ongoing.

View Audit 17290

Finding 12575 (2022-003)

Significant Deficiency 2022

Chisago County

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-003 Finding Title: Reporting Program: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: The County will have a second review done of the report before filing. A...

Finding Number: 2022-003 Finding Title: Reporting Program: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: The County will have a second review done of the report before filing. Anticipated Completion Date: Immediately

View Audit 17290

Finding 12550 (2022-004)

Significant Deficiency 2022

Henderson County Rural Health Center, INC

IL

Eligibility Significant Deficiency Internal Control / Segregation of Duties

2022-004 Community Health Centers Grant ? Assistance Listing No. 93.224/93.527 Recommendation: Management should refine and expand its internal audits of patient visits to identify instances where a patient was either assigned to the incorrect sliding fee category or billed the incorrect charges. Ex...

2022-004 Community Health Centers Grant ? Assistance Listing No. 93.224/93.527 Recommendation: Management should refine and expand its internal audits of patient visits to identify instances where a patient was either assigned to the incorrect sliding fee category or billed the incorrect charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has instituted some measures and procedure to mitigate the risk of having patients being assigned to incorrect sliding fee category or billed the incorrect charges. These additional measures and procedures include but are not limited to providing training and more oversight of the front desk and billing staff. More oversight such as regular and ongoing internal audits of the front desk and billing staff will be contacted on a quarterly basis. The objective of the regular audit is to ensure that all policies and procedures are being followed and to ensure any instances of non-compliance are timely identified and corrected. Name(s) of the contact person(s) responsible for corrective action: Matthew White, Shannon Courson, Asante Muyungga Planned completion date for corrective action plan: August 7, 2023

View Audit 17191

Finding 12508 (2022-003)

Significant Deficiency 2022

Battle Ground Healthcare

WA

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

Finding # 2022-003 (Repeat of 2021-004) Significant deficiency over allowable costs 14.218/14.228 Community Development Block Grants/ Entitlement Grants Finding: Contract billings were prepared, reviewed, and submitted by the same person and duties were not segregated for the contract billing cycle...

Finding # 2022-003 (Repeat of 2021-004) Significant deficiency over allowable costs 14.218/14.228 Community Development Block Grants/ Entitlement Grants Finding: Contract billings were prepared, reviewed, and submitted by the same person and duties were not segregated for the contract billing cycle Recommendation: The Organization should have proper segregation of duties between the preparer and the reviewer. Procedures should be put in place to ensure reviews are completed timely. Corrective Action: We plan to develop procedures to document the individuals preparing and the individuals reviewing invoices. We will review current procedures to ensure separate personnel are responsible for each function. Anticipated Completion Date: December 31, 2023

View Audit 17054

Corrective Action Plans

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