Corrective Action Plans

Finding 1169213 (2023-001)

Material Weakness 2023

SANTA CRUZ COUNTY VETERANS MEMORIAL BUILDING BOARD OF TRUSTEES

CA

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.318 § 200.327

Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.

View Audit 382113

Finding 1168603 (2023-004)

Material Weakness 2023

Line Mountain School District

PA

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District shoul...

2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District should review their record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. Action: The District will ensure that all payroll timecards are approved and signed by the appropriate supervisor before being processed for payment. The payroll clerk will not process the timecard unless it is signed and approved. Additionally, we will review the District’s record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. The District will thoroughly review timecards to avoid clerical errors in the future. Date for Completion: These steps have already been put into place and will continue to be built upon.

View Audit 380500

Finding 1168060 (2023-003)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.

View Audit 379692

Finding 1168045 (2023-002)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...

Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024

View Audit 379692

Finding 1167998 (2023-001)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024

View Audit 379692

Finding 1167984 (2023-003)

Material Weakness 2023

Lone Pine Paiute- Shoshone Reservation

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.214 § 200.303

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or d...

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or debarred prior to entering into the contract. Corrective Action: Effective January 1, 2026, every proposal or contract that goes out will require all vendors to be active in SAMS.gov for all federal grants. This will be a requirement during the biddingprocess. Anticipated date of completion: January 30, 2026.

View Audit 379637

Finding 1166943 (2023-001)

Material Weakness 2023

Mount Sinai Foundation, Incorporated 053-36322

NC

HUD Housing Programs Internal Control / Segregation of Duties § 200.302 § 200.303

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully subm...

Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2023 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 and Federal Award Program Audits Finding 2023-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2023-001 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will ensure that all transactions are properly recorded and that key accounts are reconciled and reviewed on a periodic basis beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024

View Audit 377994

Finding 1166594 (2023-001)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.

View Audit 377585

Finding 1166456 (2023-001)

Material Weakness 2023

Eastern Kentucky PRIDE, Inc.

KY

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

Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.

View Audit 377479

Finding 1166325 (2023-009)

Material Weakness 2023

Dorchester County, Maryland

MD

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

The County will implement procedures to ensure the review and approval of the monthly report is documented.

View Audit 377392

Finding 1166324 (2023-008)

Material Weakness 2023

Dorchester County, Maryland

MD

Eligibility Matching / Level of Effort / Earmarking § 200.303

The County will implement procedures to ensure the approval process is documented.

View Audit 377392

Finding 1166323 (2023-007)

Material Weakness 2023

Dorchester County, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

The County will implement a new policy to ensure all subrecipients that are given federal funds of $25,000 or more are properly monitored.

View Audit 377392

Finding 1166322 (2023-006)

Material Weakness 2023

Dorchester County, Maryland

MD

Procurement, Suspension & Debarment § 200.213 § 200.303

The County will implement a new policy to verify vendors are not suspended or debarred.

View Audit 377392

Finding 1165703 (2023-005)

Material Weakness 2023

Eldred Borough

NY

Internal Control / Segregation of Duties Reporting § 200.303

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.

View Audit 376427

Finding 1164356 (2023-002)

Material Weakness 2023

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

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

2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all empl...

2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all employees are now required to create a purchase order (PO) and obtain approvals before payments can be made. This process controlled by the finance manager creates a complete audit trail for every transaction, ensuring that all disbursements are properly documented.

View Audit 373784

Finding 1163319 (2023-004)

Material Weakness 2023

Abilities Network, Inc.

MD

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.

View Audit 372833

Finding 1163318 (2023-003)

Material Weakness 2023

Abilities Network, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.407

U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to suppo...

U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.

View Audit 372833 Questioned Costs: $1

Finding 1163191 (2023-004)

Material Weakness 2023

SAN LUIS & DELTA-MENDOTA WATER AUTHORITY

CA

Reporting § 200.303

Finding Reference Number: 2023-004 Description of Finding: The Semi-annual Federal Financial Reports (SF-425) was not submitted timely. Statement of Concurrence or Nonconcurrence: Authority staff agrees to the finding as described. Corrective Action: • An internal grant manager has been appointed to...

Finding Reference Number: 2023-004 Description of Finding: The Semi-annual Federal Financial Reports (SF-425) was not submitted timely. Statement of Concurrence or Nonconcurrence: Authority staff agrees to the finding as described. Corrective Action: • An internal grant manager has been appointed to enable closer financial oversight and we will work closely with engineering and outside consultants to ensure future grant compliance. • Director of Finance has looked into grant management certification courses in order to further educate staff on grant tracking and reporting requirements. • The Authority has since contracted with outside consultants to assist with grant management.

View Audit 372686

Finding 1162577 (2023-001)

Material Weakness 2023

Dooly County Board of Education

GA

Equipment & Real Property Management School Nutrition Programs Reporting § 200.303 § 200.313

FA 2024-001 Improve Controls over Equipment Compliance Requirement: Equipment and Real Property Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of E...

FA 2024-001 Improve Controls over Equipment Compliance Requirement: Equipment and Real Property Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 235GA32N1199 Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) S425U210012 (Year: 2021), S425W210011 (Year: 2021) Questioned Costs: None identified Prior Year Finding: FA 2022-001, FA 2021-001, FA 2020-001, FA 2019-003, FA 2018-002, FA 2017-004 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over equipment and real property management as it relates to the Child Nutrition Cluster and Elementary and Secondary School Emergency Relief Fund programs. Corrective Action Plans: Management has strengthened controls over equipment to ensure that the records are complete, accurate and r reflect all required information. We are in the process of developing a physical inventory list of equipment. The inventory listing will have all identifying information such as an item description, an identifying number, the source of funding, the title holder, the acquisition date, the cost, the percentage of federal participation in the project costs, the location of the equipment, the use and condition of the equipment, and any ultimate disposal data for each piece of equipment. A complete physical inventory will be performed each year and reconciled with the equipment listing. Estimated Completion Date: 12/31/2025 Contact Person: Christopher Stephens, Chief Financial Officer Telephone: 229-268-4761 Email: christopher.stephens@dooly.k12.ga.us

View Audit 372260

Finding 1162185 (2023-003)

Material Weakness 2023

Tippecanoe And Chapman Lakes Regional Sewer District

IN

Equipment & Real Property Management § 200.303 § 200.313

Finding 2023-003 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance...

Finding 2023-003 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Equipment and Real Property Management Audit Finding: Material Weakness, Noncompliance Condition: An effective internal control system was not in place at the District to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The District did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. There was approximately $10.9 million of disbursements from federal funds related to the project as of December 31, 2023. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will compile a capital asset listing that lists out the District’s capital assets and notes the required information, which will include the federal funding source (if applicable). The capital asset listing will be updated on an annual basis. The Board of Directors will review the capital asset listing. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect immediately.

View Audit 371994

Finding 1161991 (2023-001)

Material Weakness 2023

Center for Educational Innovation, Inc.

NY

Questioned Costs Cash Management Subrecipient Monitoring § 200.303 § 200.305

Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reco...

Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reconciled to the ledger. Once all amounts are proven, then the drawdown amounts will be initiated with the proper documentation attached.

View Audit 371855 Questioned Costs: $1

Finding 1161859 (2023-004)

Material Weakness 2023

Merrill Pioneer Community Hospital, Inc

IA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

We will work to establish written procedures and policies related to the management of Federal awards, including reporting requirements.

View Audit 371778

Finding 1161132 (2023-001)

Material Weakness 2023

Whitley County Regional Water And Sewer District

IN

Procurement, Suspension & Debarment § 200.214 § 200.303

Finding 2023-001 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment (Material Weakness) Condition: An effective internal control system was not in place at the District in order to ensure compliance with requirements related to the grant agreement and the ...

Finding 2023-001 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment (Material Weakness) Condition: An effective internal control system was not in place at the District in order to ensure compliance with requirements related to the grant agreement and the simplified acquisitions procurement method of the Procurement and Suspension and Debarment compliance requirement. Context: There were two contracts subject to procurement and suspension and debarment during the year. For both procurements, the District could only provide final signed contracts and did not have evidence of the full bid process. For the first selection, the District provided the request for proposal but did not provide all bids that were received or a scoring rubric to support why the District selected the vendor. For the second selection, the request for proposal, bids received, and scoring rubric were not provided. Additionally, evidence of a suspension and debarment check for both selections was not available. The District did not have a formal procurement policy documented. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that a procurement policy is adopted and followed and documents to support the process and vendor selections are maintained. Responsible Party and Timeline for Completion: The Treasurer is the responsible party. The completion will go into effect immediately.

View Audit 371135

Finding 1160367 (2023-002)

Material Weakness 2023

Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital

OK

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting - Material Weakness in Internal Control over Compliance Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rur...

Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting - Material Weakness in Internal Control over Compliance Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: There was no documentation of review and approval of the expenditure listing, lost revenue calculation, or the Department of Health and Human Services Period 4 report prior to submission of the HHS Period 4 report. Responsible Individuals: Dawn Ballard Corrective Action Plan: Management agrees with the finding. Due to the small accounting staff, there was little internal review of the calculations resulting in unallowed expenditures based on underlying supporting schedules that was not recognized until single audit. The Authority has adopted policies where every spreadsheet and schedule will be reviewed and checked by a second member of the Administration team as well as final review by the Contracted CPA. Anticipated Completion Date: September 29, 2023

View Audit 370750

Finding 1160366 (2023-001)

Material Weakness 2023

Choctaw County City of Hugo Hospital Authority Dba Choctaw Memorial Hospital

OK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Author...

Reporting - Material Weakness in Internal Control over Compliance and Material Noncompliance Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority selected Option 1, as defined by HRSA, to calculate lost revenue. This option consists of reporting actual revenues from relevant quarters in the period of availability with the system calculating lost revenues because of declines. The fiscal year 2021 single audit identified unallowable expenses totaling $263,861. The Authority utilized excess lost revenues at the time to cover this difference. To capture the use of these lost revenues from Period 1, the Authority should have used Option 3, as defined by HRSA, to calculate and report lost revenues. Within that calculation, lost revenues could then be reduced by the $263,861. Responsible Individuals: Dawn Ballard Corrective Action Plan: Due to the timing of completion of the 2021 single audit, which included the identification of questioned costs, and the deadline for the Period 4 Provider Relief Fund report to the HHS portal, the Period 4 report was submitted utilizing Option 1. The Authority does not expect to complete any additional HHS reports related to this program. Management will implement a process and procedures to ensure all required reports are completed accurately, in the event similar funding is received in the future. Anticipated Completion Date: January 16, 2025

View Audit 370750

Corrective Action Plans

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