Corrective Action Plans

Finding 34067 (2022-004)

Material Weakness 2022

MN

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Finding 2022-004 Finding Summary: The Hospital District?s lost revenue reported within the special report submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Responsible Individuals: Crystal Bothun, Chief Financial Officer Corrective Act...

Finding 2022-004 Finding Summary: The Hospital District?s lost revenue reported within the special report submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Responsible Individuals: Crystal Bothun, Chief Financial Officer Corrective Action Plan: We did not adjust or add any additional loss revenue to Period 2 or 3 as lost revenue was not available to be utilized under the nursing home infection control distributions received during these two periods. We will retain documentation of the adjustment to lost revenue. If any additional funding is received, we will ensure reports are properly updated to notify the Department of Health and Human Services of the Period 1 adjustment. Anticipated Completion Date: Pending. No funds have been received since Period 4 (July 1, 2021 ? December 31, 2021).

View Audit 36622

Finding 34065 (2022-004)

Material Weakness 2022

Wayne County

IN

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

FINDING 2022-004 Contact Person Responsible for Corrective Action: Auditor Mark Hoelscher Contact Phone Number: 765-973-9318 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: ARPA Quarterly & Annual Reports will be reviewed by someone other than the pr...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Auditor Mark Hoelscher Contact Phone Number: 765-973-9318 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: ARPA Quarterly & Annual Reports will be reviewed by someone other than the preparer. Anticipated Completion Date: 12-31-23

View Audit 35322

Finding 34064 (2022-003)

Material Weakness 2022

Wayne County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Auditor Mark Hoelscher Contact Phone Number: 765-973-9318 Views of Responsible Official: We concur with the findings. Wayne County Auditor's office will begin checking all contracts for suspended, debarred, or otherwise excluded from...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Auditor Mark Hoelscher Contact Phone Number: 765-973-9318 Views of Responsible Official: We concur with the findings. Wayne County Auditor's office will begin checking all contracts for suspended, debarred, or otherwise excluded from or ineligible for participation in federal assistance programs prior to the purchase. Anticipated Completion Date: December 31, 2023

View Audit 35322

Finding 34033 (2022-001)

Material Weakness 2022

Emberhope, Inc.

KS

Reporting Internal Control / Segregation of Duties Material Weakness § 200.303

Finding 2022-001: Federal Award Findings and Questioned Costs Contact person responsible for correction action ? Lance Murnan, Vice President of Finance Anticipated completion date ? April 30, 2023 Corrective action We are taking the following action: - The Director of Foster Care ? Kansas will p...

Finding 2022-001: Federal Award Findings and Questioned Costs Contact person responsible for correction action ? Lance Murnan, Vice President of Finance Anticipated completion date ? April 30, 2023 Corrective action We are taking the following action: - The Director of Foster Care ? Kansas will prepare the Quarterly Status Report and send to the Vice President of Foster Care for review. - Once the Vice President of Foster Care has reviewed the Quarterly Status Report, they will then submit to DCF to ensure accurate and timely filing.

View Audit 33437

Finding 34014 (2022-004)

Significant Deficiency 2022

Boys & Girls Clubs of the Sioux Empire, Inc.

SD

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-004 Federal Agency Name: Department of Education and Passed through State of South Dakota Department of Education Program Name: COVID-19 Education Stabilization Fund- Governor?s Emergency Education Relief (GEER) Fund FFAL # 84.425C Finding Summary: Four instances identified in which d...

Finding 2022-004 Federal Agency Name: Department of Education and Passed through State of South Dakota Department of Education Program Name: COVID-19 Education Stabilization Fund- Governor?s Emergency Education Relief (GEER) Fund FFAL # 84.425C Finding Summary: Four instances identified in which documentation could not be provided to support a formal review and approval of the expenditures prior to payment. Responsible Individuals: Scott Hupke CFO Corrective Action Plan: The State of SD, at the end of the grant period, allowed us to reallocate some of the funding to cover other expenses that went back to prior periods. Those expenses were missing the proof of formal review as the new process had not yet been put into place. We have taken corrective action and implemented an independent review of purchases to ensure they have been approved. Anticipated Completion Date: September 2022

View Audit 36738

Finding 34012 (2022-003)

Significant Deficiency 2022

Boys & Girls Clubs of the Sioux Empire, Inc.

SD

Allowable Costs / Cost Principles § 200.303 § 200.430

Finding 2022-003 Federal Agency Name: Department of Education and Passed through State of South Dakota Department of Education Program Names: COVID-19 Education Stabilization Fund- Governor?s Emergency Education Relief (GEER) Fund and Twenty-First Century Community Learning Centers Program FFAL # 84...

Finding 2022-003 Federal Agency Name: Department of Education and Passed through State of South Dakota Department of Education Program Names: COVID-19 Education Stabilization Fund- Governor?s Emergency Education Relief (GEER) Fund and Twenty-First Century Community Learning Centers Program FFAL # 84.425C and 84.287C Finding Summary: The amount of payroll taxes allocated to the GEER program exceeded the amount of payroll taxes actually paid for two of two employees tested. Additionally, one instance in which an employee?s overtime hours was not charged to the Twenty First Century Program. Lastly, one instance in which one employee?s biweekly wages were not charged to the Twenty First Century Program. Responsible Individuals: Scott Hupke CFO Corrective Action Plan: We have added an additional person in the review of the manual process for accuracy and to eliminate the errors. We will also continue to explore ways to automate the process from our payroll provider to the accounting software. Anticipated Completion Date: October 2022 for the manual process review and ongoing for the ways to automate the process.

View Audit 36738

Finding 33922 (2022-003)

Material Weakness 2022

Chicago Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Special Tests & Provisions § 200.303

Finding 2022-003 (Assistance Listing 14.881) N17. Environmental Contaminants Testing and Remediation Corrective Action Plan: ? Summary of Finding ? Special Test and Provisions The Authority was unable to provide evidence that the UPCS or the environmental inspection populations were complete and ac...

Finding 2022-003 (Assistance Listing 14.881) N17. Environmental Contaminants Testing and Remediation Corrective Action Plan: ? Summary of Finding ? Special Test and Provisions The Authority was unable to provide evidence that the UPCS or the environmental inspection populations were complete and accurate. Sixty failed UPCS inspections and forty failed environmental inspections were selected for compliance testing out of the total 9,975 failed UPCS inspections and 216 failed environmental inspections, reported by the Authority. ? Internal controls were not in place to ensure that failed UPCS and environmental inspections were remediated. ? For 35 of the 60 failed UPCS inspections tested (58%) and 14 of the 40 (35%) failed environmental inspections, the Authority did not maintain adequate supporting documentation to evidence that the safety concern from the failed inspection was remediated. ? Planned Actions: For the 2024 inspection cycle, the Authority will implement new software protocols that will automatically generate work orders to resolve findings in a failed inspection. It will track mitigations and completion of those work orders, in lieu of re-inspections. Additionally, Portfolio Management team will conduct a regular audit of work orders generated from the annual unit inspections (2%). For environmental findings, the Authority will broaden the scope of the internal inspections to include generating work orders for all findings, and securing all necessary evidence that work was remediated, and all other necessary actions have occurred. For open findings, the Authority is confirming that one or more of the following conditions exist: ? Identified remediation has taken place through a completed work order or comprehensive unit turn. ? Resident has been transferred. ? Unit is vacant, pending remediation through a comprehensive unit turn. Contact Person: Eric Garrett, Chief Property Officer Anticipated Completion Date: Q1 2024

View Audit 33257

Finding 33921 (2022-002)

Material Weakness 2022

Chicago Housing Authority

IL

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding 2022-002 (Assistance Listing 14.881) N14. Recording of Declarations of Trust/Declaration of Restrictive Covenants Against Public Housing Property Corrective Action Plan: ? Summary of Finding - Special Test Provisions There were nine of the seventeen Declarations of Trust selected for testin...

Finding 2022-002 (Assistance Listing 14.881) N14. Recording of Declarations of Trust/Declaration of Restrictive Covenants Against Public Housing Property Corrective Action Plan: ? Summary of Finding - Special Test Provisions There were nine of the seventeen Declarations of Trust selected for testing of internal controls over compliance with recording of DOTs against public housing property with deviations and a compliance exception of the following nature: ? Four instances were identified in which incorrect Property Index Numbers (PINs) were recorded within the Authority?s Excel Monitoring spreadsheet when comparing the information on the DOT. As such, the Authority?s Excel monitoring spreadsheet required updating due to inaccurate data (control deviations). ? Six instances in which the incorrect DOT addresses were recorded in the Authority?s Excel monitoring spreadsheet when compared to the DOT filed with the State of Illinois (control deviations). ? One instance was identified in which incorrect PINs were recorded within the DOT when comparing the DOT to the Authority?s DOT Excel monitoring spreadsheet. As such, a Scrivener?s Affidavit was required to be recorded by the Authority (control deviation and compliance exception). ? Planned Actions: The CHA Office of the General Counsel conducted a comprehensive quality control review of both the Authority?s Excel Monitoring spreadsheets and the recorded DOTs, in response to the 2021 audit findings related to the CHA?s DOTs. During the quality control review process, which coincided with the same timing as the 2022 audit, Legal Department staff identified and corrected all discrepancies within the foregoing documents. This undertaking included the requisite corrections noted above. The CHA Office of the General Counsel is awaiting receipt of filed documents to be returned from the County Clerk?s Office to note the recording information on the respective Excel spreadsheets for accurate reference. Once this update is completed, all Excel spreadsheets will be locked allowing only one point of date entry by the Office of the General Counsel, while making the spreadsheets available as a ?read-only? file. Going forward, the quality control efforts to be undertaken will be to make sure that new DOTs are accurately prepared and identified on the Excel spreadsheets. Contact Person: Ellen M. Harris, Chief Legal Officer Anticipated Completion Date: End of 1st Qtr. 2024

View Audit 33257

Finding 33920 (2022-001)

Material Weakness 2022

Chicago Housing Authority

IL

HUD Housing Programs Eligibility Allowable Costs / Cost Principles § 200.303

Finding 2022-001 (Assistance Listing 14.881) Eligibility and Reporting (Form HUD-50058 MTW) Public Housing and Rental Assistance Demonstration (RAD) Corrective Action Plan: ? Summary of Finding ? Eligibility and Reporting ? Internal Controls ? There were four Public Housing tenants and three RAD ...

Finding 2022-001 (Assistance Listing 14.881) Eligibility and Reporting (Form HUD-50058 MTW) Public Housing and Rental Assistance Demonstration (RAD) Corrective Action Plan: ? Summary of Finding ? Eligibility and Reporting ? Internal Controls ? There were four Public Housing tenants and three RAD tenants for which control deviations were noted (8.8% overall MTW deviation rate). In the case that a recertification was to be performed in 2022, the nature of the control deviations are as follows: ? The examination/re-examination checklist was not initialed by the certification specialist (CS); therefore, the Authority did not retain evidence that the CS inspected all relevant forms (three instances). ? The examination/re-examination checklist was initialed by the CS, but forms were missing and/or not signed (one instance). ? Relevant forms were signed after the effective date and submittal to HUD (three instances). ? Relevant forms were missing and/or missing signature by the tenant and CS (five instances). ? Summary of Finding ? Eligibility and Reporting ? Compliance In addition, there were twelve compliance exceptions noted out of 100 tenants selected for the MTW program (12.0% overall MTW exception rate). ? The recertification was to be performed in 2022, relevant forms were missing and/or missing signature by tenant and recertification clerk (eight instances). ? The recertification was to be performed in 2022, third-party income support was not available and/or on file (four instances). ? The recertification was to be performed in 2022, third-party income support did not match the calculation amount (one instance). ? The recertification was to be performed in 2022, but was not performed within a reasonable timeframe (two instances). ? The recertification was to be performed, proper documentation was not available and/or on file to tie key line items within Form HUD-50058: total annual income, date of birth, and social security number (two instances). ? The recertification was to be performed in 2022, the reexamination file could not be located (one instance). ? Planned Actions: On March 31, 2023, a comprehensive, in-person training on the `Perfect File Folder? was conducted. It was inclusive of Private Property Management (PPM) firms for both Public Housing and RAD properties. By the end of 2023, each site will have and be required to maintain (and update as needed) a blank Perfect File Folder for site reference. Additionally, the Authority will require certification by the PPMs that 100% of the tenant files that have been reviewed in a calendar year have also been audited and purged. The Authority?s Portfolio Management team will conduct regular audit sampling from the files that have been certified as audited by the PPMs. Contact Person: Eric Garrett, Chief Property Officer Anticipated Completion Date: Q4 2023

View Audit 33257

Finding 33759 (2022-004)

Material Weakness 2022

Clay Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2022-004 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Business Affairs (currently John Szabo) will co...

FINDING 2022-004 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Business Affairs (currently John Szabo) will compile information and complete the Annual Reports, which will be reviewed and signed-off on by Assistant Superintendent (currently Tim Rayle) to ensure accuracy of information being submitted. Anticipated Completion Date: Immediately, as of the next required report submission.

View Audit 29668

Finding 33756 (2022-006)

Material Weakness 2022

Clay Community Schools

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.303

FINDING 2022-006 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Real time reporting will be compiled by the Data Management...

FINDING 2022-006 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Real time reporting will be compiled by the Data Management Specialist (currently Stephanie Jackson) and will be reviewed by the Title I Grant Coordinator (currently Tim Rayle). Annual Financial reports will be compiled by the Director of Business Affairs (currently John Szabo), and prior to submission those reports will be reviewed by the Title I Grant Coordinator. Anticipated Completion Date: July 2023

View Audit 29668

Finding 33755 (2022-005)

Material Weakness 2022

Clay Community Schools

IN

Matching / Level of Effort / Earmarking § 200.303

FINDING 2022-005 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Business Affairs will maintain a workbook with ...

FINDING 2022-005 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Director of Business Affairs will maintain a workbook with regards to matching level of effort and earmarking. Calculations will be done periodically to ensure compliance, and this information will be reviewed and approved by the Title Grant Coordinator for the corporation (currently Tim Rayle). Periodically, with reimbursement requests made for expenditures from Title I grants, the Director of Business Affairs will check to make sure that the corporation is making the appropriate expenditures related to parent involvement. Director of Business Affairs will work with Title Grant Coordinator throughout the grant year to ensure that the corporation is on target to meet the minimum required expenditure level for this type of expenditure. Anticipated Completion Date: July 2023.

View Audit 29668

Finding 33744 (2022-003)

Material Weakness 2022

Clay Community Schools

IN

Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

FINDING 2022-003 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: When appropriate, the Food Services Director will employ a ...

FINDING 2022-003 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number: 812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: When appropriate, the Food Services Director will employ a minimum three vendor rotation for Micro Purchases, and use effective reasoning when applicable. Director of Human Resource will review the use of these vendors on an ongoing basis. For intermediate purchases between $10,000 and $150,000, the Asst. Food Services Director will solicit at least three quotes. Once a vendor is selected, a contract will be executed and signed by the Asst. Food Services Director and the Director of Human Resources or another designated Director. For purchases over $150,000, formal bidding procedures including proper advertising and formal Board of Trustees approval. Once a vendor is selected by the Board of Trustees a contract will be executed and signed by the Asst. Food Services Director and the Director of Human Resources or another designated Director. Anticipated Completion Date: August 1, 2023

View Audit 29668

Finding 33743 (2022-002)

Material Weakness 2022

Clay Community Schools

IN

Allowable Costs / Cost Principles School Nutrition Programs Procurement, Suspension & Debarment § 200.303 § 200.403

FINDING 2022-002 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number:812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In order to monitor allowable costs, the Food Services Direc...

FINDING 2022-002 Contact Person Responsible for Corrective Action: John Szabo, Director of Business Affairs Contact Phone Number:812-443-4461 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: In order to monitor allowable costs, the Food Services Director (currently Patricia Woolery) will review billing statements and insure that costs being billed to the school corporation are consistent with purchasing agreements that are in place. Food Services Director will communicate with vendors and review any communication from vendors in regards to price variance of items. Even though it may not be reasonable to double check each individual item ordered, Food Services Director will spot check an appropriate number of items to insure accuracy of costs. Anticipated Completion Date: August 1, 2023

View Audit 29668

Finding 33681 (2022-003)

Material Weakness 2022

Winslow Memorial Hospital D/b/a Little Colorado Medical Center

AZ

Material Weakness Reporting Internal Control / Segregation of Duties § 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 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end...

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 Compliance Requirement: Reporting Finding Summary: The Hospital did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 2 when reporting lost revenue. Responsible Individuals: John J Dempsey, Chief Executive Officer, Lona King, Chief Financial Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports to reflect the yearend adjustments in the appropriate quarter. Anticipated Completion Date: March 31, 2023

View Audit 31569

Finding 33668 (2022-005)

Significant Deficiency 2022

State of Kansas

KS

Eligibility Matching / Level of Effort / Earmarking § 200.303

Recommendation: We recommend that DCF have internal controls in place to mitigate this from happening in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The first case is from Feb. 2008 and the other o...

Recommendation: We recommend that DCF have internal controls in place to mitigate this from happening in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The first case is from Feb. 2008 and the other one is from May 2014. While there were several documents provided from those two cases, missing from that, was nonrecurring expense documentation. The staff persons identified with both cases were from the SN County (NE Region). Neither staff member identified is still currently employed with DCF. KDCF has a policy that all casefiles contain documentation to support any state expenditure, as well as documentation to support all payments, (reference Policy #0430 Contents of Foster Care, Adoption and Independent Living Services Case Records). Internally, we have quarterly meetings with adoption staff and specialists, as well as monthly meetings with Regional Foster Care Administrators. We will discuss the audit findings and the importance of properly maintaining all the adoption and subsidy related paperwork. It is vital all of documents can be accounted for in the adoption files. We will stress that files be double-checked to make sure they have all items in place before being filed. Name(s) of the contact person(s) responsible for corrective action: Corey Lada, Adoption Program Manager Planned completion date for corrective action plan: March/April 2023

View Audit 33298

Finding 33665 (2022-007)

Material Weakness 2022

State of Kansas

KS

Subrecipient Monitoring Reporting § 200.303

Recommendation: We recommend that KDCF and KHRC implement a process that includes ensuring the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDCF will implement a FFATA re...

Recommendation: We recommend that KDCF and KHRC implement a process that includes ensuring the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDCF will implement a FFATA reporting process to ensure timely submission of subawards for all subrecipient agreements. KDCF will update FFATA reporting procedures to include transfers of federal fund to other state agencies and any subawards to other organizations. Staff will be designated to make sure FFATA reporting deadlines are met going forward to avoid future audit findings. KDCF has posted for a new position in the Office of Grants and Contracts that will be responsible to assuring all FFATA reporting is completed timely. Name(s) of the contact person(s) responsible for corrective action: Brian Carlgren, Deputy Director of Fiscal Services Laura Lewien, Post Award Manager Planned completion date for corrective action plan: April 2023

View Audit 33298

Finding 33663 (2022-004)

Significant Deficiency 2022

State of Kansas

KS

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Recommendation: We recommend that KDCF implement a process that includes tracking the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDCF will implement a FFATA reporting...

Recommendation: We recommend that KDCF implement a process that includes tracking the timely submission of the FFATA reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDCF will implement a FFATA reporting process to ensure timely submission of subawards for all subrecipient agreements. KDCF will update FFATA reporting procedures to include transfers of federal fund to other state agencies and any subawards to other organizations. Staff will be designated to make sure FFATA reporting deadlines are met going forward to avoid future audit findings. KDCF has posted for a new position in the Office of Grants and Contracts that will be responsible to assuring all FFATA reporting is completed timely. Name(s) of the contact person(s) responsible for corrective action: Brian Carlgren, Deputy Director of Fiscal Services Laura Lewien, Post Award Manager Planned completion date for corrective action plan: April 2023

View Audit 33298

Finding 33658 (2022-014)

Significant Deficiency 2022

State of Kansas

KS

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.331

Recommendation: We recommend the agency obtain certifications from vendor stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarre...

Recommendation: We recommend the agency obtain certifications from vendor stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. We recommend that the agency have proper procedures in place to ensure that all contractual documentation is maintained and able to be located. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDHE is in the process of implementing a new contract system which will include steps for verifying suspension and debarment status for all contracts and sub-recipient agreements which KDHE is a party to. Name(s) of the contact person(s) responsible for corrective action: Kelly Chilson Planned completion date for corrective action plan: July 1, 2023

View Audit 33298

Finding 33657 (2022-013)

Material Weakness 2022

State of Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Recommendation: We recommend the agency obtain certifications from vendor stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarre...

Recommendation: We recommend the agency obtain certifications from vendor stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDHE will ensure that all contractual agreements developed in house have either a certification from the contractor or reflect verification in the System for Award Management for suspension and/or debarment. KDHE will make the Department of Administration aware of this finding and request their cooperation in implementing procedures for those contracts approved by their office but cannot guarantee that they will comply with the request. Name(s) of the contact person(s) responsible for corrective action: Kelly Chilson Planned completion date for corrective action plan: May 2023

View Audit 33298

Finding 33656 (2022-012)

Material Weakness 2022

State of Kansas

KS

Subrecipient Monitoring § 200.303 § 200.331

Recommendation: We recommend that the agency review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding. Explanation of disagreement with audit finding: There is...

Recommendation: We recommend that the agency review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The sub-recipient expenditures in question were funds distributed to support COVID-19 Staffing & Infrastructure, Expanded Infrastructure, Care Resource Coordination and Expanded Testing. The critical need to get the funds paid out quickly for support at the height of the pandemic resulted in an alternative document being used as the Subaward agreement instead of the established Sub-Recipient Agreement which contains the required information. KDHE has since developed an alternative document that can be used on an exception basis that will facilitate a faster payment process in the event that a future Public Health Emergency or other situation would require that Subawards be made that due to time constraints cannot follow the established Sub-Recipient Agreement process. The alternative document contains the required information. Name(s) of the contact person(s) responsible for corrective action: Kelly Chilson Planned completion date for corrective action plan: April 1, 2023

View Audit 33298

Finding 33655 (2022-011)

Significant Deficiency 2022

State of Kansas

KS

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

Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed and submitted in a timely manner as well as increase training efforts on reporting requirements if there is future staffing turnover. Explanation of disagreement with audit finding: There is no disag...

Recommendation: We recommend the agency implement procedures to ensure reports are properly reviewed and submitted in a timely manner as well as increase training efforts on reporting requirements if there is future staffing turnover. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The performance measures for the Epidemiology and Laboratory Capacity Cooperative Agreement projects were submitted into CDC RedCap during this audit period and as before there are no dates that are documented when the reports are electronically submitted. This is a problem with the CDC-ELC system. They are now migrating to ELC-CAMP which is based on the Salesforce platform with greater functionality. The exports of these reports now have a date / time stamp which will be utilized moving forward and should correct audit finding. Name(s) of the contact person(s) responsible for corrective action: Sheri Tubach Planned completion date for corrective action plan: Upon implementation of ELC-CAMP, February 2023

View Audit 33298

Finding 33641 (2022-015)

Significant Deficiency 2022

State of Kansas

KS

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

Recommendation: We recommend that internal controls are in place to ensure that cases are reviewed within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BAM investigators were pulled to a...

Recommendation: We recommend that internal controls are in place to ensure that cases are reviewed within the required timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BAM investigators were pulled to assist other areas of KDOL during the pandemic and once returned to BAM had an enormous backlog to catch up on. The unit has also struggled with staffing issues, both in number and UI knowledge/experience. We currently have 3 full-time BAM Auditors and 1 full-time Lead. We just hired an additional BAM Auditor who is currently in training. We have been working together with the Training department, BAM Manager, and BAM Lead to provide consistent and regular feedback on general UI knowledge as well as case-specific coding details. We will continue with both real-time feedback and scheduled training. We are also seeking to hire 1-2 additional BAM Auditors in the next year. We have recently implemented a new task management software to assist with better case organization and transparency for Supervisor to view/assist with current open cases. With staffing changes, modern software, and detailed training we should be able to complete BAM cases within the federal guidelines. BAM Lead and Manager meet weekly to review open cases and strategize methods to complete cases. Name(s) of the contact person(s) responsible for corrective action: Donna Njuki Planned completion date for corrective action plan: December 31, 2023

View Audit 33298

Finding 33627 (2022-002)

None 2022

American Bureau of Shipping

TX

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

Finding 2022-002 ? Budget to Actual Analysis Cluster: Research and Development Supporting Agency: Department of Health and Human Services and Department of Energy Award Names: Development and Testing a Field-based Hazard/Near-Miss Sharing System for Commercial Fishing Vessels and Aerodynamic Turbine...

Finding 2022-002 ? Budget to Actual Analysis Cluster: Research and Development Supporting Agency: Department of Health and Human Services and Department of Energy Award Names: Development and Testing a Field-based Hazard/Near-Miss Sharing System for Commercial Fishing Vessels and Aerodynamic Turbines, Lighter and Afloat, with Nautical Technologies and Integrated Servo-control (ATLANTIS) Award Numbers: U01OH012288 and DE-AR0001188 Assistance Listing Title: Occupational Safety and Health Program and Advanced Research Projects Agency - Energy Assistance Listing Number: 93.262 and 81.135 Award Year: FY 2022 To ensure that ABS is in compliance with 2 CFR 200.303, ABS is updating its Contracted Research and Development Process Instruction to outline appropriate communication and coordination for budget to actual analysis of all research and development projects and to ensure appropriate documentation is maintained. The updated process instruction will articulate the designation of project managers to formally document a consistent review of budgets to actuals cost analysis on a quarterly basis. The process instruction will further ensure the documentation accounts for the review of cost allowability, and the project manager will sign and date as verification of a completed review. The anticipated completion date is the first quarter of 2024.

View Audit 35586

Finding 33624 (2022-001)

Material Weakness 2022

Mary Lanning Memorial Hospital Association

NE

Reporting Internal Control / Segregation of Duties § 200.303

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition...

Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Hospital inadvertently miskeyed a number when reporting ?2022 actuals (calendar year)? patient care revenue within the Period 4 Department of Health and Human Services report submission process. Previous Response for Finding: Management agrees with the noted finding. Corrective Action: Management will continue to monitor and enhance its internal controls over federal award compliance to ensure proper reporting of revenue. Planned Completion Date: Ongoing Person Responsible: Shawn Nordby, CFO

View Audit 34389

Corrective Action Plans

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