Corrective Action Plans

Finding 7943 (2023-005)

Material Weakness 2023

NE

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.327

Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The ...

Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System did not obtain quotes from multiple vendors as it relates to the procurement and purchasing of flooring which was over the micro-purchase threshold. In addition, the Health System did not have a written procurement policy or written standards of conduct policy related to procurement. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a procurement policy and standards of conduct policy related to procurement, implement internal control processes to ensure compliance with their procurement policy, and retain documentation to support procurement, suspension and debarment procedures performed. Anticipated Completion Date: 01/31/2024

View Audit 10349

Finding 7942 (2023-004)

Material Weakness 2023

Tri Valley Health System

NE

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Wea...

Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024

View Audit 10349 Questioned Costs: $1

Finding 7921 (2023-001)

Significant Deficiency 2023

Association of University Centers on Disabilities

MD

Reporting Internal Control / Segregation of Duties § 200.303

Views of Responsible Officials: New program staff was hired to provide added capacity and trained on the invoicing process and the bill.com system. Furthermore, the Program Director is developing and implementing a clear, written procedural protocol that will eliminate this issue in the future.

View Audit 10327

Finding 7838 (2023-002)

Significant Deficiency 2023

Rio Rancho Public School District No. 94

NM

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.303 § 200.306 § 200.308 § 200.403

Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made...

Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made. On occasion, payment requests do not have an invoice number. To prevent duplicate payments, the Accounts Payable staff require original invoices and uses a system generated invoice number, or a will use a manual entry numbering convention to prevent duplicate invoice numbers. The invoice data is entered by an Accounts Payable specialist and reviewed by the Accounts Payable Manager. On occasion, A/P must request corrected invoices from vendors who try and reuse invoice numbers. The A/P Manager reviews invoice numbers during the check run for accuracy. Purchasing and A/P will also periodically review the vendor database for duplicate vendors. For construction projects that list a pay application number instead of an invoice number, A/P will implement a consistent invoice numbering convention to avoid duplicate payments. The A/P specialists will also review the PO payment history prior to processing. Responsible party(ies) for corrective action(s): Accounts Payable Manager Corrective action(s) timeline: December 1, 2023

View Audit 10190 Questioned Costs: $1

Finding 7831 (2023-004)

Significant Deficiency 2023

Cherry County Hospital

NE

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Condition: The Hospital reported amounts in the reporting portal for information technology expenditures for Quarter 3 2022 in excess of amounts that are supported by audit evidence. Planned Corrective Action: Management will continue to refine processes to more diligently review the calculation of...

Condition: The Hospital reported amounts in the reporting portal for information technology expenditures for Quarter 3 2022 in excess of amounts that are supported by audit evidence. Planned Corrective Action: Management will continue to refine processes to more diligently review the calculation of allowable expenses and amounts entered into the provider relief fund reporting portal. Contact Person: Stephanie Jacobsen, Interim Chief Financial Officer Anticipated Completion Date: March 31, 2024

View Audit 10165

Finding 7607 (2023-001)

Significant Deficiency 2023

Somerton Elementary School District No. 11

AZ

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.439

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jorge Cano, Director of Food Service Anticipated Completion Date: January 1, 2024 Planned Corrective Action: The District plans to en...

Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jorge Cano, Director of Food Service Anticipated Completion Date: January 1, 2024 Planned Corrective Action: The District plans to ensure that all program costs are allowable and in adherence to applicable federal requirements. This includes submitting Capital Expenditure Pre‐Approval Request Forms to ADE for approval prior to purchasing equipment items that are not listed on ADE’s approved equipment list.

View Audit 9955 Questioned Costs: $1

Finding 7582 (2023-002)

Material Weakness 2023

Franciscan Missionaries of Our Lady Health System, Inc.

LA

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

Corrective Action Plan The reconciliation review process will be enhanced for funding that applies to multiple funding periods. Anticipated Completion Date To be corrected with the Period 6 PRF portal submission Name of Contact Person for Corrective Action Rebecca Villar, Director of Accounting

View Audit 9933

Finding 7581 (2023-001)

Material Weakness 2023

Franciscan Missionaries of Our Lady Health System, Inc.

LA

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

Corrective Action Plan Transition the St. Dominic payroll to be processed centrally at the System in accordance with all System's processes and procedures. Anticipated Completion Date January 1, 2022 Name of Contact Person for Corrective Action Amanda Hymel, Corporate Controller

View Audit 9933 Questioned Costs: $1

Finding 7577 (2023-004)

Material Weakness 2023

Bethany Lutheran Home for the Aged, Inc.

SD

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookk...

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookkeeping and bank account. However, management transposed the $116,400 amount that was required to be in the reserve account according to the Letter of Conditions. The Organization underfunded the actual reserve balance after interest earnings by $521 as of June 30, 2023. Additionally, the Organization withdrew $100,000 in May 2023 from the reserve account to deposit into the operating account and subsequently replenished the reserve account within 14 days without obtaining proper federal agency approval. Responsible Individuals: Dalton Huber, Chief Financial Officer Corrective Action Plan: A new line of credit has been established at First Interstate Bank to prevent this from reoccurring. The correct amount is presently in the reserve account. Anticipated Completion Date: 10/1/2023

View Audit 9917

Finding 7569 (2023-003)

Material Weakness 2023

Stillwater Area Public Schools Independent School District #834

MN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Material Weakness § 200.303

U.S Department of Education 2023-003 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all covered trans...

U.S Department of Education 2023-003 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all covered transactions entered into with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures as necessary to ensure that all procurements which are charged to federal programs are fully documented. Name(s) of the contact person(s) responsible for corrective action: Marie Schrul, Executive Director of Finance Planned completion date for corrective action plan: January 31, 2024

View Audit 9887

Finding 7565 (2023-002)

Significant Deficiency 2023

Stillwater Area Public Schools Independent School District #834

MN

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.321

U.S Department of Education 2023-002 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District puts in place the proper procedures for sufficiently documenting all procurements and methodology used. Explanation of disagreement with audit finding...

U.S Department of Education 2023-002 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District puts in place the proper procedures for sufficiently documenting all procurements and methodology used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures as necessary to ensure that all procurements which are charged to federal programs are fully documented, including support for noncompetitive proposals. Name(s) of the contact person(s) responsible for corrective action: Marie Schrul, Executive Director of Finance Planned completion date for corrective action plan: January 31, 2024

View Audit 9887 Questioned Costs: $1

Finding 7560 (2023-004)

Material Weakness 2023

Stillwater Area Public Schools Independent School District #834

MN

Procurement, Suspension & Debarment Material Weakness School Nutrition Programs § 200.303

U.S Department of Agriculture 2023-004 Child Nutrition Cluster – Assistance Listing No. 10.533, 10.555, 10.555C, 10.559 Recommendation: CLA recommends the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all...

U.S Department of Agriculture 2023-004 Child Nutrition Cluster – Assistance Listing No. 10.533, 10.555, 10.555C, 10.559 Recommendation: CLA recommends the District follow its procurement policies as well as requirements within the Uniform Guidance to perform the proper verification procedures on all covered transactions entered into with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures as necessary to ensure that all procurements which are charged to federal programs are fully documented. Name(s) of the contact person(s) responsible for corrective action: Marie Schrul, Executive Director of Finance Planned completion date for corrective action plan: January 31, 2024

View Audit 9887

Finding 7530 (2023-002)

Significant Deficiency 2023

Second Harvest Heartland

MN

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

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Scanning Applications: o Applications are physically filed by volunteers, th...

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Scanning Applications: o Applications are physically filed by volunteers, then scanned into SharePoint and filed electronically. o SharePoint does not recognize hand-written applications, so we use a filing spreadsheet to track specific batch numbers for applications, which gives us the ability to trace an individual document. If the document is typed, then it can be recognized through a search in SharePoint.  Our SOP document for scanning applications can be found on the CSFP Sharepoint site. o We have two volunteers who are scanning on a weekly basis (between 150-250 applications scanned weekly), and we will continue to prioritize this project as more staff/volunteer hours become available. • If an application is missing: o Confirm that application information is in ClientTrack and document through a generated printed application. o Send application to distribution site for next distribution, to ensure participant signs new application before they receive another CSFP box. Anticipated Completion Date: We currently have two volunteers who are scanning on a weekly basis (between 150-250 applications scanned weekly), and we will continue to prioritize this project as more staff/volunteer hours become available. The current backlog is around one year with plans to get caught up using additional resources in the next few months.

View Audit 9830

Finding 7529 (2023-001)

Significant Deficiency 2023

Second Harvest Heartland

MN

Allowable Costs / Cost Principles § 200.303

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Site Coordinator verifies what Site Partner reports as distributed numbers t...

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Site Coordinator verifies what Site Partner reports as distributed numbers through counting signatures and confirms with distribution log from Site Partner. o Site Coordinator then writes number of signatures counted/verified, with their initials, on log cover printed from Site Distribution spreadsheet. • Then, another Site Coordinator recounts signatures and verifies that the signatures counted/verified match what is on the cover sheet, and initials cover sheet. Additionally, they will then verify that the signatures counted/verified match what is in the Side Distribution spreadsheet. • Paperwork is then filed by month. Monthly paperwork is reconciled by staff/volunteers who check that all components are included, and that all paperwork is accounted for. o Paperwork is then stored in warehouse once missing paperwork/missing components have been accounted for/documented [secondary verification]. Anticipated Completion Date: The updated monthly signature verification process will begin with the November 2022 set of site paperwork. The monthly paperwork reconciliation process was implemented with staff/volunteers in August 2023.

View Audit 9830

Finding 7516 (2023-003)

Material Weakness 2023

Platte Health Center

SD

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

Single Audit Finding 2023-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Health Center does not have controls in place to ensure compliance with the requirements as th...

Single Audit Finding 2023-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Health Center does not have controls in place to ensure compliance with the requirements as they have not been calculating or monitoring the required debt ratios. The Health Center was relying on annual calculations performed by the Eide Bailly audit team. Responsible Individuals: Vicki Jensen, Chief Financial Officer Corrective Action Plan: Platte Health Center will perform debt service ratio and working capital calculations and implement a review process over the calculations as part of their year-end close process to ensure all covenants of the loan are met. Anticipated Completion Date: June 30, 2024

View Audit 9749

Finding 7392 (2023-002)

Material Weakness 2023

Douglas County, Nv

NV

Subrecipient Monitoring Matching / Level of Effort / Earmarking Material Weakness § 200.303 § 200.329

Finding 2023-002 Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing: 21.027 Federal Agency: U.S. Department of the Treasury Passed-through: N/A Award Year: 2022-2023 Compliance Requirement: Reporting Grant Award Number: Applies to all awards wi...

Finding 2023-002 Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing: 21.027 Federal Agency: U.S. Department of the Treasury Passed-through: N/A Award Year: 2022-2023 Compliance Requirement: Reporting Grant Award Number: Applies to all awards with findings and no specific grant award. Type of Finding: Material Instance of Noncompliance, Material Weakness in Internal Controls over Compliance Management’s Response: We concur. Views of Responsible Officials and Corrective Action: Management agrees with the finding and understands the importance of properly reporting federal and will institute a multi-step review system before such reporting is finalized and submitted. Name of Responsible Person: Terri Willoughby, CFO Name of Department Contact: Finance Projected Implementation Date: January 1, 2024

View Audit 9528

Finding 7373 (2023-003)

Material Weakness 2023

Pipestone County Medical Center

MN

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year- Period 4 TIN# 411392082 Federal Financial Assistance Listing #93.498 Finding Summary:...

Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year- Period 4 TIN# 411392082 Federal Financial Assistance Listing #93.498 Finding Summary: There were expenses claimed under the general and administrative category that were in excess of the amounts actually incurred under the program. Also, there was a duplication of utility expenses already claimed for the month of November 2021. Responsible Individuals: Sandra Schlechter, Chief Financial Officer, and Bradly Burris, Chief Executive Officer Corrective Action Plan: We had Sandra Schlechter, Chief Financial Officer, and Ryan Hill, Controller, review all the forms and expenses to make sure there are no duplications. There were additional unreimbursed expenses and excess lost revenue on the Period 4 report to cover this oversight. Anticipated Completion Date: December 31, 2023, as no further reporting requirements are anticipated for this program.

View Audit 9501

Finding 7067 (2023-001)

Significant Deficiency 2023

North Hill Communities. Inc. and Subsidiaries

MA

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

The Company agrees with the finding. The Company will implement a process for a member of the finance staff to prepare lost revenues calculations. The Director of Finance will then provide a second layer of detailed review on the lost revenue calculations and the financial reporting to ensure amount...

The Company agrees with the finding. The Company will implement a process for a member of the finance staff to prepare lost revenues calculations. The Director of Finance will then provide a second layer of detailed review on the lost revenue calculations and the financial reporting to ensure amounts captured are accurate and categorized appropriately. Sign off on preparation and review will be documented appropriately.

View Audit 9075

Finding 6926 (2023-001)

Significant Deficiency 2023

Heart of West Michigan United Way

MI

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding Number: 2023-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The grant is complete for payment for direct assistance to eligible participants. Contact person responsible for corrective action: Gail Montgomery, Vice Preside...

Finding Number: 2023-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The grant is complete for payment for direct assistance to eligible participants. Contact person responsible for corrective action: Gail Montgomery, Vice President of Finance Anticipated Completion Date: August 30, 2023

View Audit 8922

Finding 6866 (2023-001)

Material Weakness 2023

Holland Hospital

MI

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.303

Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed una...

Finding Number: 2023-001 Condition: The Hospital's controls in place for submitting expenses did not identify that several invoices and related expense amounts were duplicated in the addendum to the period 1 submission. As a result, period 1 addendum submission included expenses that were deemed unallowable as they had already been utilized to support funding received. Reimbursement for, the original period 1 submission contained retention bonus costs that exceeded 20% of total funds awarded. Planned Corrective Action: The Hospital will review its processes surrounding submission of expenses to MHA and implement additional layers of review. Contact person responsible for corrective action: Brenda Winn and Alex Roehling Anticipated Completion Date: 9/30/2023

View Audit 8819

Finding 6858 (2023-002)

Significant Deficiency 2023

Career and Recovery Resources, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303

2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds 2022-2023 Funding U.S. Department of Treasury Recommendation: The Agency should update its payroll allocation spr...

2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds 2022-2023 Funding U.S. Department of Treasury Recommendation: The Agency should update its payroll allocation spreadsheets to agree with the approved timesheets per payroll period to ensure only allowable payroll costs are charged to grants. Corrective Action: The Agency had a turnover of finance staff in 2022-23 that created an inconsistent review of the allocation spreadsheet. The Agency did not receive reimbursements from any grantor due to an error in the allocation calculations. The allocation spreadsheet and timesheets will be reconciled as part of the monthly close. Responsible Party: Senior Accountant and Director of Human Resources Date Expected to be Corrected: Immediately If the U.S. Department of Treasury and U.S. Department of Veteran Affairs have any questions regarding this plan, please contact Nkechi “Nikki” Agwuenu, new CEO, at 713.754.7083

View Audit 8806 Questioned Costs: $1

Finding 6855 (2023-003)

Significant Deficiency 2023

Career and Recovery Resources, Inc.

TX

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303

2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, VA Supportive Services for Veteran Families – Shallow Subsidy, and VA Supportive Services for Veteran Families – Legal Services 20...

2023-002 Compliance and Internal Controls over Allowable Costs (Significant Deficiency) Assistance Listing Number 64.033 VA Supportive Services for Veteran Families, VA Supportive Services for Veteran Families – Shallow Subsidy, and VA Supportive Services for Veteran Families – Legal Services 2021-2022 and 2022-2023 Funding U.S. Department of Veteran Affairs Recommendation: The Agency should update its payroll allocation spreadsheets to agree with the approved timesheets per payroll period to ensure only allowable payroll costs are charged to grants. Corrective Action: The Agency had a turnover of finance staff in 2022-23 that created an inconsistent review of the allocation spreadsheet. CRR did not receive reimbursements from any grantor due to an error in the allocation calculations. The allocation spreadsheet and timesheets will be reconciled as part of the monthly close. Responsible Party: Senior Accountant and Director of Human Resources Date Expected to be Corrected: Immediately If the U.S. Department of Treasury and U.S. Department of Veteran Affairs have any questions regarding this plan, please contact Nkechi “Nikki” Agwuenu, new CEO, at 713.754.7083

View Audit 8806 Questioned Costs: $1

Finding 6846 (2023-001)

Material Weakness 2023

Liberty Towers Incorporated of Clarion

PA

Procurement, Suspension & Debarment Eligibility HUD Housing Programs § 200.303

2023-01 - Section 223(f) Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, ALN #14.155 Statement of Condition: The Project does not have sufficient internal controls in place over eligibility Response: Developac, Inc., Management Agent, will immediately im...

2023-01 - Section 223(f) Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, ALN #14.155 Statement of Condition: The Project does not have sufficient internal controls in place over eligibility Response: Developac, Inc., Management Agent, will immediately implement the following corrective actions to cure said deficiency: 1. Management Agent will be solely responsible for updating housing software with the annual income limits provided by HUD 2. Management Agent will periodically review tenant move-in files for eligibility verification

View Audit 8772

Finding 6653 (2023-004)

Material Weakness 2023

Logan Health

MT

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalis...

Finding 2023-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: The operations of HealthCenter Northwest, LLC (HC) were consolidated into Kalispell Regional Medical Center d/b/a Logan Health Medical Center (LHMC) as of December 31, 2020. When LHMC calculated their lost revenues, they included HC’s revenue for both 2020 and 2021 instead of only the 2021 information. This resulted in LHMC reporting higher lost revenues than the detailed reports supported in Period 3. This was corrected in Period 4 reporting. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal has been updated in Period 4. Completion Date: 12/31/23

View Audit 8606

Finding 6652 (2023-003)

Material Weakness 2023

Logan Health

MT

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expens...

Finding 2023-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: In some of the quarters for certain entities, it was noted that bad debt expenses were higher than revenues, creating a negative revenue for the quarter. As the HHS reporting portal would not allow negative amounts to be entered, a zero was entered into the HHS reporting portal. These negative amounts should have been offset to other quarters or other revenue line items, but were not, which resulted in higher revenue amounts being reported than the detailed reports supported for two locations for Period 3. Responsible Individuals: Craig Lambrecht, CEO and Cole Turner, CFO Corrective Action Plan: The lost revenue calculation for these two locations will be re-evaluated and the amount of lost revenue reported on the HHS reporting portal will be updated in future periods. Anticipated Completion Date: Ongoing

View Audit 8606

Corrective Action Plans

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