Corrective Action Plans

Finding 504075 (2022-017)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2022-017 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-0001 COVID-19 Emergency Solutions Grant Program - 14.231, Award number E-20-MW-20-0001 Management’s Response: Management agrees it is important to adhere to the terms o...

Finding 2022-017 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-0001 COVID-19 Emergency Solutions Grant Program - 14.231, Award number E-20-MW-20-0001 Management’s Response: Management agrees it is important to adhere to the terms of the award. During 2022 we experienced a cyber event that delayed timely payments for certain supplier invoices. Details on the dates of late payments are requested to determine if the issue was a system wide shut down due to the cyber event April – June 2022. Regardless, the new Workday system is now fully implemented (as of January 2024) and we will work to use the system to ensure timely payments. Views of Responsible Officials and Corrective Action: Departmental stakeholders should work with central accounting to be sure payments are made in time and develop solutions where there could potentially be a shortfall. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504074 (2022-016)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs HUD Housing Programs Material Weakness § 200.303

Finding 2022-016 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-20-0001 Management’s Response: Management agrees it is critical to ensure spending occurs within the applicable expenditure periods. In the new financial management sy...

Finding 2022-016 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-20-0001 Management’s Response: Management agrees it is critical to ensure spending occurs within the applicable expenditure periods. In the new financial management system (Workday), we have established parameters to fence the applicable expenditure periods. Further we are making gains to close out awards to further disallow spend outside the applicable expenditure periods. There was departmental turnover within the department at the end of 2022 with a loss of knowledge transfer during the change in personnel. Views of Responsible Officials and Corrective Action: With the aid of technology available through our new ERP system, management plans to enhance operations by having training documents and processes for various awards so as personnel attrition occurs there is continuity in processes. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473 Questioned Costs: $1

Finding 504073 (2022-015)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs Matching / Level of Effort / Earmarking HUD Housing Programs § 200.303

Finding 2022-015 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-20-0001 Management’s Response: Management agrees that the matching component should be tracked to ensure compliance with the terms of the award. Views of Responsible O...

Finding 2022-015 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-20-0001 Management’s Response: Management agrees that the matching component should be tracked to ensure compliance with the terms of the award. Views of Responsible Officials and Corrective Action: With our new ERP system, in the grant/award module, the Unified Government of Wyandotte County & Kansas City KS are working with departments to establish match components and trackable spend items to enhance compliance with award terms. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473 Questioned Costs: $1

Finding 504072 (2022-014)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding 2022-014 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: Management agrees that reports should be available for all reporting periods. It was discovered in 2023 during document submittals that reports were stored...

Finding 2022-014 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083 Management’s Response: Management agrees that reports should be available for all reporting periods. It was discovered in 2023 during document submittals that reports were stored on the individual’s local computer and not reposed on the network. Key personnel turnover led to the reports not being available. The IT department has ensured that the documents stored locally on individual computer are now backed up by the network to prevent future issues, and compliance reports are to be stored on the department network drive and shared with Finance for a central depository. Views of Responsible Officials and Corrective Action: Management has begun the process of centralizing documents related to reporting, monitoring and compliance. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504071 (2022-013)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2022-013 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083, Award Number EMW-2019-FF-0819 Management’s Response: Management agrees spend controls are an important part of grant compliance. Management continues to improve compliance and ...

Finding 2022-013 U.S Department of Homeland Security Staffing for Adequate Fire and Emergency Response (SAFER) – 97.083, Award Number EMW-2019-FF-0819 Management’s Response: Management agrees spend controls are an important part of grant compliance. Management continues to improve compliance and controls over awards to ensure compliance. In 2023 we converted to a new ERP system and part of the conversion was implementing spend controls to aid in compliance for awards to minimize future issues. Views of Responsible Officials and Corrective Action: Management will work with stakeholders so that only the allowed costs are used as the basis of the reimbursement packet. We have also created fencing around allowed costs and period of performance in our new ERP system. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504070 (2022-012)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

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

Finding 2022-012 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that compliance reporting timing is important to grant management. The Unified Government of Wyandotte County & Kansas City KS experienced delay...

Finding 2022-012 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that compliance reporting timing is important to grant management. The Unified Government of Wyandotte County & Kansas City KS experienced delays in reporting as a direct result of a cyber security event that occurred for the period of April 2022 – June 2022. There were also issues with the federal reporting system due to the Treasury having the City and County as two separate entities. Both issues have been resolved and all reports have been submitted in a timely manner in 2023 and to date in 2024. Views of Responsible Officials and Corrective Action: In concert with our ARPA consultant, we were able to combine the City & County on the portal and report timely quarterly since this initial issue in the reporting portal. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504069 (2022-011)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Procurement, Suspension & Debarment § 200.214 § 200.303

Finding 2022-011 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that debarment and suspension checks are a important aspect of award management. Views of Responsible Officials and Corrective Action: Managem...

Finding 2022-011 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that debarment and suspension checks are a important aspect of award management. Views of Responsible Officials and Corrective Action: Management will train department staff related to the debarment and suspension checks and ensure that Procurement is aware of this requirement as part of the procurement process. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504068 (2022-010)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.412 § 200.414

Finding 2022-010 U.S Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Childre – 10.557 Award number 202222W100643 Management’s Response: Management agrees it is imperative to foster collaboration for successful award management. Finance leads the annual ef...

Finding 2022-010 U.S Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Childre – 10.557 Award number 202222W100643 Management’s Response: Management agrees it is imperative to foster collaboration for successful award management. Finance leads the annual effort working with an outside consultant to calculate the indirect rate using information supplied by Unified Government of Wyandotte County & Kansas City KS. The annual indirect rate will be calculated annually for use by all departments in the spring and available by July 1 each fiscal year. This will be used consistently across all departments unless the State of Kansas rate is permitted by the grant. Finance will work to find the best way to make the information easily accessible to grant program managers embedded in departments. After the audit, management received an authorization letter from the Kansas Department of Health and Environment (KDHE) that supported the indirect rate we used for Jul2022-Dec2022, however because the letter was dated in 2024, we are still subject to this finding. Views of Responsible Officials and Corrective Action: Management will work internally to complete the annual calculation of the indirect rate and develop a solution, a shared document solution to provide indirect rate information to departments in a consistent and timely manner. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473 Questioned Costs: $1

Finding 504067 (2022-009)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs Matching / Level of Effort / Earmarking § 200.303

Finding 2022-009 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM Management’s Response: Management co...

Finding 2022-009 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM Management’s Response: Management concurs. Program management will monitor expenditures to ensure they align with budgeted amounts and earmarking requirements. The Unified Government of Wyandotte County & Kansas City KS will put processes and controls in place to ensure earmarking is being monitored for compliance. Views of Responsible Officials and Corrective Action: Management will put controls and processes in place to ensure earmarking is being monitored for compliance. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473 Questioned Costs: $1

Finding 504064 (2022-008)

Material Weakness 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Subrecipient Monitoring § 200.303 § 200.332

Finding 2022-008 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the ...

Finding 2022-008 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the Aging_Title III, Part C_Nutrition Services – 2201KSOCAHC Management’s Response: Management concurs. Risk assessments are an important component of award management. We have developed a risk assessment tool for use by department personnel in risk assessments for sub recipients. Views of Responsible Officials and Corrective Action: Department grant management personnel will receive training around risk assessments and provided our monitoring tool for their assessments. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 504061 (2022-007)

Significant Deficiency 2022

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Finding 2022-007 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the ...

Finding 2022-007 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the Aging_Title III, Part C_Nutrition Services – 2201KSOCAHC Management’s Response: Management concurs. Debarment and suspension checks are an important aspect of award management. Views of Responsible Officials and Corrective Action: Department grant management personnel and procurement will need to ensure that these checks are happening prior to engaging in supply chain events with suppliers. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

View Audit 326473

Finding 503686 (2022-005)

Material Weakness 2022

North Fork Area Transit

NE

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.430

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over payroll transactions in order to comply with laws, regulations, and grant agreements. Additionally, the pass-through entity has increased its ...

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over payroll transactions in order to comply with laws, regulations, and grant agreements. Additionally, the pass-through entity has increased its documentation requirements which helps the Organization ensure that it possesses compliant payroll documentation. Further, the Organization plans to review its personnel files to ensure that adequate documentation exists to support approved rates of pay. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Partially implemented. Personnel file review anticipated completion December 31, 2024.

View Audit 325903 Questioned Costs: $1

Finding 503685 (2022-004)

Material Weakness 2022

North Fork Area Transit

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.305 § 200.403

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over non-payroll transactions such that all expenditures can be properly explained with supporting documentation, and all expenditures are reviewed...

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization has strengthened its internal controls over non-payroll transactions such that all expenditures can be properly explained with supporting documentation, and all expenditures are reviewed and approved prior to payment. Additionally, the Organization only submits expenditures for reimbursement that have been paid. While the Office of Management and Budget allows the reimbursement of expenditures that have been incurred, the pass-through entity will only reimburse expenditures that have been paid. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date Already implemented.

View Audit 325903 Questioned Costs: $1

Finding 503450 (2022-007)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend management implement a review process to check individual's compensation charged to federal grants against annual federal limitations prior to drawdown of funds. Explanation of disagreement with audit finding...

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend management implement a review process to check individual's compensation charged to federal grants against annual federal limitations prior to drawdown of funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement review processes to identify individuals over federal wage limitations moving forward before being charged to federal grants. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563 Questioned Costs: $1

Finding 503449 (2022-006)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.303

Health Centers Cluster, Provider Relief Fund – Assistance Listing No. 93.2242/93.527, 93.498 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to...

Health Centers Cluster, Provider Relief Fund – Assistance Listing No. 93.2242/93.527, 93.498 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563

Finding 503448 (2022-005)

Significant Deficiency 2022

West Side Community Health Services INC

MN

Cash Management Reporting Significant Deficiency § 200.303

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend reviewing reconciliation procedures between detailed grant expenditures and summary schedules used in reporting/draw down requests to ensure sufficient detail to support draw downs. Also recommend a detailed ...

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend reviewing reconciliation procedures between detailed grant expenditures and summary schedules used in reporting/draw down requests to ensure sufficient detail to support draw downs. Also recommend a detailed review and approval process for federal grant eligible expenditures and draw downs, to identify issues prior to draw down or reporting in the future. Documentation should be retained to support review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and improve reconciliation and review process around eligible expenditures for federal grants, and drawdowns of federal funds. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

View Audit 325563

Finding 503189 (2022-002)

Material Weakness 2022

City of Manhattan, Kansas

KS

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...

Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.

View Audit 325285

Finding 502268 (2022-004)

Significant Deficiency 2022

American Association of Physics Teachers, Inc.

MD

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

Finding 2022-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 ...

Finding 2022-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1726113 (8/1/2017 – 9/30/2023), 1907950 (7/1/2019 – 6/30/2024), 2141745 (5/1/2022 – 4/30/2027), 2212807 (7/1/2022 – 6/30/2026) Federal Program: Research and Development Cluster (Mathematical and Physical Sciences) Assistance Listing Number and Title: 47.049 Mathematical and Physical Sciences Name of Federal Agency, Pass Through Entity, Award Number and Year: National Science Foundation: 1821372 (10/1/2018 – 9/30/2024 pass through entity American Physical Society) Condition: Payroll approvals for individuals are not always made by individuals who are the employee’s supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Of the 63 individual payroll payments tested to 12 separate individuals, totaling $105,046 charged to federal grants, we identified 38 total payments to 7 separate individuals, totaling $43,704, where the timesheet was approved by the CFO, who we do not consider to be knowledgeable of the employee’s activities during a given pay period. Five of these seven individuals were full-time employees and the other two were part-time employees. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correctly reflect the employee’s assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 324376

Finding 502267 (2022-002)

Material Weakness 2022

American Association of Physics Teachers, Inc.

MD

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

Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1500529 (9/1...

Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022), 1720869 (5/15/2017 – 4/30/2022), 1726113 (8/1/2017 – 9/30/2023), 1821462 (7/1/2018 – 6/30/2024), 1940925 (1/15/2020 – 12/31/2023), 1907950 (7/1/2019 – 6/30/2024), 2015205 (4/1/2020 – 3/31/2022), 2021059 (10/1/2020 – 9/30/2024), 2141745 (5/1/2022 – 4/30/2027), 2212807 (7/1/2022 – 6/30/2026) Federal Program: Research and Development Cluster (Mathematical and Physical Sciences) Assistance Listing Number and Title: 47.049 Mathematical and Physical Sciences Name of Federal Agency, Pass Through Entity, Award Number and Year: National Science Foundation: 1821372 (10/1/2018 – 9/30/2024 pass through entity American Physical Society), 1834530 (9/1/2018 – 8/31/2025 pass through entity American Physical Society), 1938815 (8/1/2020 – 7/31/2024) Federal Program: Research and Development Cluster (Science) Assistance Listing Number and Title: 43.001 Science Name of Federal Agency, Pass Through Entity: National Aeronautics and Space Administration: NNX16AR36A (8/24/2016 – 8/23/2021 pass through entity Temple University of the Commonwealth System of Higher Education), 80NSSC21K1560 (6/28/2021 – 6/27/2022 pass through entity Temple University of the Commonwealth System of Higher Education), 80NSSC22K1071 (5/23/2022 – 5/22/2023)Condition: The Chief Financial Officer is responsible for posting entries into the accounting system without a second level review, and obtaining all bank statements unopened while also having the ability to add or modify payees and unilaterally initiate and authorize electronic fund transfers such as automated clearing house payments. The CFO is also responsible for opening the mail which may contain payments by check, and can manually reduce receivable balances. Views of Responsible Officials and Planned Corrective Actions: AAPT has instituted the segregation of duties of submitting and approval of electronic payments. The senior accountant has been authorized to submit the ACH/Wire transfer requests. The CFO has the authorization of approval of submitted electronic payments. The change was activated during March, 2024 The staff will be trained on generating journal entries previously prepared by the CFO and supervised and approve by the CFO – completed date May 15, 2024 The administrative assistant of the CEO will come to AAPT twice weekly to process incoming mail and create an initial recordation log of checks or cash received. The administrative assistant will not have access in any system to enter/modify/delete any information related to checks that are received. Anticipated Completion Date: January 2025 Responsible Official: Michael Brosnan, CFO

View Audit 324376

Finding 501923 (2022-005)

Material Weakness 2022

Hill & Dales General Hospital and Subsidiary

MI

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation claimed expenses that were reim...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation claimed expenses that were reimbursed by other funding sources. These expenses were improperly included in the HHS Special Report which caused the report to be inaccurate. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: The Corporation will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and ensure are properly recorded in the report required to be submitted to the federal agency. The Corporation will also implement a review process to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: March 31, 2024

View Audit 324085 Questioned Costs: $1

Finding 501922 (2022-004)

Material Weakness 2022

Hill & Dales General Hospital and Subsidiary

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation’s final lost revenue calculatio...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation’s final lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program did not agree to the amount claimed in the report submitted to the Department of Health and Human Services for Period 3 and Period 4. Additionally, the Corporation’s total net patient care revenues did not agree to the amount in the report submitted to the Department of Health and Human Services for Period 4. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: Management will implement a control process which includes monitoring over amounts reported relating to lost revenue amounts and the related calculation. Anticipated Completion Date: March 31, 2024

View Audit 324085

Finding 501921 (2022-003)

Material Weakness 2022

Hill & Dales General Hospital and Subsidiary

MI

Allowable Costs / Cost Principles Eligibility Material Weakness § 200.303

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation did not have an adequate intern...

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Initial Fiscal Year Finding Occurred: 2021 Finding Summary: The Corporation did not have an adequate internal control policy in place to ensure review and approval of the lost revenue calculation and report submitted to the Department of Health and Human Services for Period 3 and Period 4. Responsible Individuals: Renee Henry, Corporate Controller Corrective Action Plan: Management will implement a control process which includes a secondary review and approval of any future lost revenue calculation and report submitted under the federal program. Anticipated Completion Date: March 31, 2024

View Audit 324085

Finding 501897 (2022-002)

Material Weakness 2022

Access, INC

CA

Questioned Costs Cash Management Material Weakness § 200.303

Management will undertake the following corrective actions to address the material weakness identified: 1.Provide additional training to staff involved in payroll processing. 2.Establish procedures and implement more precise controls to ensure that expenditures are properly reviewed and approved bef...

Management will undertake the following corrective actions to address the material weakness identified: 1.Provide additional training to staff involved in payroll processing. 2.Establish procedures and implement more precise controls to ensure that expenditures are properly reviewed and approved before being charged to a federal award.

View Audit 324040 Questioned Costs: $1

Finding 499398 (2022-003)

Material Weakness 2022

City of Gary

IN

Allowable Costs / Cost Principles § 200.303 § 200.403

FINDING 2022-003 Contact Person Responsible for Corrective Action: M. Celita Green Contact Phone Number:219-881-1363 Views of Responsible Official: We concur Description of Corrective Action Plan: While it has been confirmed that most of the firefighters are currently receiving the corrected overtim...

FINDING 2022-003 Contact Person Responsible for Corrective Action: M. Celita Green Contact Phone Number:219-881-1363 Views of Responsible Official: We concur Description of Corrective Action Plan: While it has been confirmed that most of the firefighters are currently receiving the corrected overtime wages as calculated by Department of Labor, it has recently been learned that the formula that was used to calculate the corrected wages has not been shared with the Fire Department. We will be working with the Fire Department in obtaining the corrected formula to use, so that Fire Staff will be able to approve the correct pay, prior to it being paid by payroll. Anticipated Completion Date: December 31, 2024

View Audit 322250

Finding 499189 (2022-001)

Material Weakness 2022

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

AUDIT FINDINGS 2022-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, review controls over ...

AUDIT FINDINGS 2022-001: There were not adequate controls related to the reporting of expenditures on the schedule of expenditures of federal awards (Schedule) for the COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (FEMA). Specifically, review controls over the accuracy and completeness of the Schedule were not designed to operate at an appropriate level of precision for the discretely presented component unit. As a result, $1,795,854 of FEMA expenditures was inadvertently omitted from the December 31, 2022 Schedule. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Implement a control of management review at an appropriate level of precision for the discretely presented component unit in order to ensure the accuracy and completeness of the Schedule. Anticipated Completion Date: September 2023 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2022-001.

View Audit 321987

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