Corrective Action Plans

Finding 40125 (2022-001)

Material Weakness 2022

IN

Equipment & Real Property Management Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.313

FINDING 2022-001 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812)829-2233 Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure ...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812)829-2233 Views of Responsible Official: We concur with Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the School Corporation and 3rd Party Inventory Vendor includes all required information on all property purchased with federal funds that is outlined in 2 CFR 200.313(d)(1). The Treasurer will list items that are purchased with federal funds and forward that information to the 3rd Party Vendor. Once the report from the 3rd Party Vendor is received either the Treasurer/Deputy Treasurer/Grant Administrator will review the report to ensure all required information has been included on all items purchased with federal funds. Anticipated Completion Date: Will begin this process moving forward with any property purchased after February 2023.

View Audit 53434

Finding 40121 (2022-002)

Material Weakness 2022

Spencer-Owen Community Schools

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to en...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Annette Brown, Treasurer Contact Phone Number: (812) 829-2233 Views of Responsible Official: We concur with the Audit Finding Description of Corrective Action Plan: The School Corporation will implement procedures and processes to ensure that the reporting compliance requirement is met for the Education Stabilization Fund. All reporting information will be gathered either by the Treasurer, Payroll Clerk or Accounts Payable depending on the information being requested. The information will then be reviewed for accuracy by the Grant Administrator or Superintendent before being submitted. All documentation will be signed and dated by the appropriate individuals and be filed with the appropriate ESF. Anticipated Completion Date: Will begin this process moving forward with future reporting after February 2023.

View Audit 53434

Finding 40099 (2022-001)

Significant Deficiency 2022

Providence St. Joseph Health

WA

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

Providence Corrective Action Plan Year ended December 31, 2022 Contact: Nate Johnson, Senior Manager Finance nathaniel.johnson@providence.org Finding 2022-001 Statement of Condition: During testwork over allowability, a sample of 60 payments was selected for testing. Within the sample, 1 selection...

Providence Corrective Action Plan Year ended December 31, 2022 Contact: Nate Johnson, Senior Manager Finance nathaniel.johnson@providence.org Finding 2022-001 Statement of Condition: During testwork over allowability, a sample of 60 payments was selected for testing. Within the sample, 1 selection was identified where the charges submitted for reimbursement to HRSA were unallowable. Further, as the charges submitted were not properly reviewed this is an instance of the Health System?s internal control not operating as designed. Corrective Action Plan: Management will prioritize strengthening our processes and controls before proceeding. Management will add a layer of review for all potential new claims. All accounts will be audited by management prior to submission to ensure compliance. Management will do a post submission audit to confirm billing compliance on paid claims. This will be implemented by December 31, 2023.

View Audit 41243 Questioned Costs: $1

Finding 40098 (2022-001)

Significant Deficiency 2022

Aids Foundation Houston, Inc.

TX

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

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Yea...

September 26, 2023 AIDS Foundation Houston, Inc. dba Allies in Hope respectfully submits the following corrective action plan in response to our single audit results for the year ended December 31, 2022. Carr, Riggs & Ingram, LLC Two Riverway, 15th Floor Houston, Texas 77056 Audit Period: Fiscal Year January 1, 2022 ? December 31, 2022 The finding from the schedule of findings and questioned costs dated September 26, 2023, is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 Internal Controls over Reporting (Significant Deficiency) Recommendation: The Foundation review its controls and ensure that the copies of the submission emails be part of the Foundation?s grant records. Corrective Action: Effective 10/1/23 we are using a shared system to house and track our reporting to our funders and will save emails sent to funders in this shared system in order to document the submission of the reports. Responsible Parties: Chief Financial Officer, Chief Program Officer, and Director of Compliance Date Expected to be Corrected: 10/1/23 If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please contact Nicholas Williams, CFO at 713-623-6796 x285. Sincerely yours, Nicholas Williams Nicholas Williams Chief Financial Officer

View Audit 48673

Finding 40066 (2022-005)

Significant Deficiency 2022

Legal Services Alabama, INC

AL

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

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@al...

Finding 2022-005 ? Internal Control over Reporting (Significant Deficiency) Corrective Action: LSA will resume a review and approval of every grant report and document the review as of the date of this audit report. Contact Person: David Roberson, Director of Finance; (334) 223-0251; droberson@alsp.org

View Audit 45011

Finding 39994 (2022-005)

Significant Deficiency 2022

One Vision

IA

Allowable Costs / Cost Principles Eligibility Reporting § 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 Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowe...

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: The Organization?s Period 2 report to HHS included expenditures that were not properly supported. Responsible Individuals: Mario Van Dijk, CFO Corrective Action Plan: Management is aware of the expenditures, even though small in amount, that were not properly supported, and lost revenue calculation and some of the expenditure listings not being reviewed separate from the preparer. The organization has created processes around preparing and reviewing for items such as this. The finance team is committed to these changes to improve accuracy of our work. Anticipated Completion Date: September 28, 2023

View Audit 45801

Finding 39993 (2022-004)

Material Weakness 2022

One Vision

IA

Allowable Costs / Cost Principles 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 Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Findin...

Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Applicable Federal Award Number and Year ? Period 2 TIN #420953968 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Organization selected option ii to calculate lost revenue, which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. For the periods that the Organization did not have an approved budget, the Organization calculated lost revenues using a budget approved by their board after March 27, 2020. The Organization also did not adjust patient revenue for certain adjusting entries identified as part of the financial statement audit, which should have been included to calculate net patient revenue. In addition, the Organization, did not back out lost revenues that had been claimed by other funds. When the Organization tried to reopen their report during the single audit, the Organization was informed that amendments were not allowed. Finally, the Organization?s lost revenue claimed under the program as an allowable cost was not fully reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Mario Van Dijk, CFO Corrective Action Plan: Our budget for FY 2020 was approved prior to the March 2020 deadline identified. We therefore used Method 2 since the budget had been approved. However, we should?ve used Method 3 which would?ve allowed FY 2021 and later to compare actual to budget. We contacted HRSA during our single audit to try and have our reporting reopened so that we could amend the reporting, however that request was denied. If we had been able to reopen our report, we also would have adjusted lost revenue for adjusting entries identified as part of the financial statement audit and other sources that used lost revenue. However, the total lost revenue used to claim PRF would not have changed as we had significant excess lost revenue, so net effect in changes would be none. Anticipated Completion Date: September 28, 2023

View Audit 45801

Finding 39953 (2022-003)

Significant Deficiency 2022

City of Laguna Hills

CA

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

Finding 2022-003 Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Finding Summary: Review of SEFA Responsible Individuals: Eric Hendrickson, Finance Director Corrective Action Plan: The...

Finding 2022-003 Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Financial Assistance Listing Number: 21.027 Federal Agency: U.S. Department of Treasury Finding Summary: Review of SEFA Responsible Individuals: Eric Hendrickson, Finance Director Corrective Action Plan: The Finance Department will prepare the SEFA and have it reviewed by the appropriate higher authority prior to submitting the document to the auditors. Anticipated Completion Date: 06/30/2023

View Audit 37900

Finding 39933 (2022-002)

Significant Deficiency 2022

The Rogosin Institute, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2022-002 ? I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Defense, Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No. / FAIN: 12.420 / W81XWH180620 93.847 / RC2DK125960 93.84...

Finding 2022-002 ? I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Department of Defense, Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No. / FAIN: 12.420 / W81XWH180620 93.847 / RC2DK125960 93.847 / R24DK106743 93.847 / UC2DK126021 / MDI Biological Laboratory / UC2DK126021-02/Rogosin 93.847 / R56DK125960 / UT Southwestern Medical Center / GMO210101 PO0000002155 93.847 / R01DK131050 / Joan & Sanford I. Weill Medical College of Cornell University / 213209 / 225880 Section III ? Federal Award Findings and Questioned Costs (continued) 93.847 / U01DK123786 / University of Washington / UWSC11731 93.847 / R01DK115468 / University of Washington / UWSC10982 93.847 / U01DK123813 / Trustees of the University of Pennsylvania / 577985 93.855 / R21AI164093 / Joan & Sanford I. Weill Medical College of Cornell University / 211581 / 222908 Views of responsible officials and planned corrective actions: Management concurs with this audit finding and will enhance the suspension and debarment review process and controls to meet the requirements of 2 CFR part 200. Name of responsible official: Name ? Lauren Everson Title ? Director of Finance, NYP Phone: (212-297-3325) Email: jrh9009@nyp.org Projected completion date: December 31, 2023

View Audit 37679

Finding 39917 (2022-001)

Material Weakness 2022

The University of Chicago

IL

Student Financial Aid Eligibility Period of Performance § 200.303

CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: The Registrar's Office has implemented a comparison process where graduates are verified against the National Student Clearinghouse grad only file. Implementation Date: 8/21/22 Corrective Action: The Registrar's O...

CFDA Numbers: Various Program: Student Financial Assistance Cluster Corrective Action: The Registrar's Office has implemented a comparison process where graduates are verified against the National Student Clearinghouse grad only file. Implementation Date: 8/21/22 Corrective Action: The Registrar's Office has implemented a process to verify SSNs on record and correct student records. Implementation Date: 1/20/22 Corrective Action: The Registrar's Office will develop a business process to review term withdrawals for program/campus level discrepancies. Implementation Date: 6/12/23 Contact Person: Scott Campbell and Amanda Fijal

View Audit 48521

Finding 39872 (2022-001)

Material Weakness 2022

Froedtert Health, Inc. and Affiliates

WI

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

Froedtert Health, Inc. and Affiliates Audit in Accordance with Uniform Guidance: Corrective Action Plan Year Ended June 30, 2022 Finding Number: 2022-001 Agency: Department of Health and Human Services Contact Person: David Dirksmeyer, Director of Corporate Finance Corrective Action: Froedtert He...

Froedtert Health, Inc. and Affiliates Audit in Accordance with Uniform Guidance: Corrective Action Plan Year Ended June 30, 2022 Finding Number: 2022-001 Agency: Department of Health and Human Services Contact Person: David Dirksmeyer, Director of Corporate Finance Corrective Action: Froedtert Health agrees with the finding. Prospectively, Froedtert Health will ensure that all controls relating to review of Provider Relief Fund portal submissions are effectively designed to ensure compliance with regulations for federal funding and are operating effectively. Date of Completion: September 30, 2023

View Audit 47950

Finding 39866 (2022-001)

Material Weakness 2022

Special Olympics Indiana, Inc.

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.319 § 200.320

Recommendation: The Auditor noted the Organization should consider implementing policies, procedures, and internal controls specific to federal awards which are in writing and are approved by the appropriate level of management or those charged with governance. Planned Corrective Action: Management ...

Recommendation: The Auditor noted the Organization should consider implementing policies, procedures, and internal controls specific to federal awards which are in writing and are approved by the appropriate level of management or those charged with governance. Planned Corrective Action: Management agrees with the recommendation and has implemented the following steps. A procurement policy, compliant with the Procurement Standards codified in 2 C.F.R. ? 200.317 through ? 200.327 has been approved by the Board of Directors. This policy states the procedures required for documentation for procurement of goods and services related to all Federal awards. Specific additional procedures have been implemented providing an additional level of review for all Federal expenditures, including a quarterly reconciliation of reporting submitted to the granter.

View Audit 37544

Finding 39816 (2022-005)

Significant Deficiency 2022

Pueblo County Colorado

CO

Procurement, Suspension & Debarment § 200.303

Recommendation: We recommend the County obtain certifications from vendors 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 debarr...

Recommendation: We recommend the County obtain certifications from vendors 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: The County will ensure that any entity that receives American Rescue Plan (APRA) funding is not suspended or debarred as well as ensure that they are registered on SAM.gov before any funds are disbursed by the County. An addendum is being added to all current and new contracts that will require signed certification from the vendors/contractors related to debarment and registration with SAM.gov. Name(s) of the contact person(s) responsible for corrective action: Sherri Crow, Interim Director of Budget and Finance Planned completion date for corrective action plan: January 1, 2024

View Audit 34720

Finding 39815 (2022-004)

Material Weakness 2022

Pueblo County Colorado

CO

Subrecipient Monitoring § 200.303 § 200.331 § 200.332

Recommendation: We recommend that the County 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 and that appropriate monitoring is performed for each subr...

Recommendation: We recommend that the County 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 and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that all subrecipients of American Rescue Plan (APRA) funds are monitored by using appropriate subrecipient monitoring procedures to ensure compliance with the grant awarded throughout the contract period. Name(s) of the contact person(s) responsible for corrective action: Sherri Crow, Interim Director of Budget and Finance Planned completion date for corrective action plan: January 1, 2024

View Audit 34720

Finding 39798 (2022-005)

Significant Deficiency 2022

Avoyelles Parish Police Jury

LA

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

CONTEXT: Eighteen employees were identified as eligible workers and were deemed qualified to receive premium pay. These eligible workers received premium pay payments in FY 21 and FY 22, resulting in eight employees receiving total payments which exceeded $25,000. RECOMMENDATION: Procedures should ...

CONTEXT: Eighteen employees were identified as eligible workers and were deemed qualified to receive premium pay. These eligible workers received premium pay payments in FY 21 and FY 22, resulting in eight employees receiving total payments which exceeded $25,000. RECOMMENDATION: Procedures should be established to ensure that all grant award rules and regulations are interpreted correctly and followed. VIEWS OF RESPONSIBLE OFFICIALS: See corrective action plan for current audit findings.

View Audit 37940 Questioned Costs: $1

Finding 39691 (2022-004)

Significant Deficiency 2022

Cook County, Illinios

IL

Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.430

Please allow this correspondence to serve as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to the audit findings. During the FY2022 Single Audit, six audit findings were identified by Washington, Pittman & McKeever, LLC. CCH and CCDPH will address the recommen...

Please allow this correspondence to serve as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to the audit findings. During the FY2022 Single Audit, six audit findings were identified by Washington, Pittman & McKeever, LLC. CCH and CCDPH will address the recommendations of the auditors by taking the following Corrective Action Plans (CAP) outlined below: Finding 2022-004: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from Program Leads and the Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by the established County Policy. Correction Action: The CCH Director of Grants Accounting will be responsible for training the Program Leads and Account Payable (AP) unit to ensure proper supporting documents are attached to each invoice as required by the established County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.

View Audit 37825

Finding 39689 (2022-005)

Significant Deficiency 2022

Cook County, Illinios

IL

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Finding #2022-005: regarding CCDPH not adequately complying with federal regulations over allowable costs. Cause: The cause of this finding resulted from not following the estab...

Finding #2022-005: regarding CCDPH not adequately complying with federal regulations over allowable costs. Cause: The cause of this finding resulted from not following the established controls that ensure proper support documentation is included with the journal entry chargeback entries prepared by Finance staff to justify the charges incurred to the Grant. Additionally, the Program Lead (key personnel) assigned to the program left the organization prior to the Grant ending which affected the periodic review for allowable costs/charges. Corrective Action: The CCH Director of Grant Accounting will reinforce current internal controls so that the reviewer/approver (staff who prepares the chargeback) includes proper supporting documents and attaches to the entries in the EBS Oracle System. Additionally, the CCH Director of Grant Accounting will continue to reinforce current CCH procedures and ensure Grant expenditures are periodically reviewed and checked for allowability and reasonableness (based on activities) by both the Finance and Programmatic areas. Anticipated completion of the corrective action will be December 31, 2023.

View Audit 37825 Questioned Costs: $1

Finding 39688 (2022-010)

Significant Deficiency 2022

Cook County, Illinios

IL

Cash Management Reporting Allowable Costs / Cost Principles § 200.303

Subject: Corrective Action Plan For: Finding 2022-010 Cook County Health would like to respond to the finding related to the Provider Relief Fund {PRF) Phase 2 Reporting. The FY'22 SEFA amount (including both lost revenues and expenditures) for the HRSA PRF Phase 2 Reporting period was $31,163,323...

Subject: Corrective Action Plan For: Finding 2022-010 Cook County Health would like to respond to the finding related to the Provider Relief Fund {PRF) Phase 2 Reporting. The FY'22 SEFA amount (including both lost revenues and expenditures) for the HRSA PRF Phase 2 Reporting period was $31,163,323.35. Cause: The cause of this finding resulted from a misunderstanding of the expense data that was rolling/ inputted in the HRSA portal. The Unreimbursed Expenses line should have been inputted as Other PRF Expenses. CCH Management has instituted the following Corrective Action Plan (CAP) to prevent future occurrence. Corrective Action Plan: To ensure accurate data is reported, CCH has implemented the following corrective action plan: ? Any future HRSA- PRF Audit Portal data submission will require multiple reviews. The review will be led by CCH Finance's Associate Chief Financial Officer to ensure the report is accurate and complete prior to submission. Status - Phase 4 PRF Reporting was reviewed on March 28th, 2023, by the CFO and ACFO prior to submission. ? To buttress this CAP, CCH has created a dedicated GL account code to track all PRF activities - lost revenue, cash disbursed, and expenses incurred. Fully Implemented since - (August 30th, 2022) ? A recurring monthly reconciliation meeting has been instituted to track lost revenues, and expenses that were paid with PRF and not through any other type of assistance. Recurring Monthly Reconciliation Leader- Scott Spencer, Associate Chief Financial Officer. Please note that CCH has not received any PRF funding since January 2022.

View Audit 37825

Finding 39685 (2022-007)

Significant Deficiency 2022

Cook County, Illinios

IL

Allowable Costs / Cost Principles § 200.303 § 200.403 § 200.430

Finding #2022-007: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from the Progr...

Finding #2022-007: regarding not maintaining adequate controls over allowable costs as required by Federal regulations. Cause: The cause of this finding resulted from the Program Leads and Accounts Payable unit not following the established requirements for properly supporting invoices for services provided. The invoices that were attached in EBS Oracle were insufficient as required by County Policy. Correction Action: The CCH Director of Grant Accounting will be responsible for training the Program Leads and Account Payable (AP) staff to ensure proper supporting documents are attached to each invoice as required by County Policy. In the event the AP unit determines more supporting documentation is needed, then the Program Director/Lead will assist in obtaining proper supporting documents from partnered subrecipients and/or vendors. Supporting documents may include additional timesheets, payroll registers, T&E justification, etc. Issues will be flagged (based on assessed risk) by applying requirements identified in the CCH Subrecipient Monitoring Policy. Anticipated completion of the corrective action will be December 31, 2023.

View Audit 37825

Finding 39585 (2022-006)

Significant Deficiency 2022

Village of Tijeras

NM

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.302 § 200.303

Recommendation We recommend the Village review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete and timely. Management Response Corrective Acti...

Recommendation We recommend the Village review the instructions for completion of the federal financial reports with training provided to the program staff preparing and reviewing the federal financial reports to ensure submitted reports are complete and timely. Management Response Corrective Action: The Village recognizes the need for improved oversight of its grant-funded capital projects and has hired a full-time Grant Writer/Administrator who will work in conjunction with the Clerk and Finance Director to monitor grant activities, submit reports and requests for payment in a timely manner, and ensure all program requirements are met. Village staff will receive training on the reporting and administration requirements of grant-funded programs. Village staff will maintain regular communication with funding agency liaisons to ensure that required reports are prepared accurately and submitted timely. Due Date of Completion: June 2023 Responsible Party: Finance Director and Village Clerk

View Audit 34655

Finding 39531 (2022-002)

Significant Deficiency 2022

Sanford

SD

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

Finding 2022-002 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing: 93.498; COVID-19 Provider Relief Fund ...

Finding 2022-002 ? Activities Allowed or Unallowed and Allowable Costs/Cost Principles Information on the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing: 93.498; COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Award Year: 2022 Planned corrective actions: Sanford?s preventative and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being used for unallowable contract labor costs. Sanford believes that the risk of any material contract labor costs being incorrectly charged to a federal grant is effectively mitigated through existing preventative and detective internal controls. Sanford will re-educate the senior care facility?s administrators and enhance its procedural documentation regarding retention of evidence related to the approval of contract labor timecards and payment of contract labor invoices for this facility to be consistent with the over 200 other facilities across the system. Responsible official: Dustin Scholz, Executive Director of Operations Anticipated completion date: August 31, 2023

View Audit 34025

Finding 39508 (2022-001)

Significant Deficiency 2022

Sanford

SD

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.213 § 200.303

Finding 2022-001 ? Suspension and Debarment Information on the federal program: Federal Agency: Various Assistance Listing: Various; Research and Development Cluster Award Year: 2022 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and deb...

Finding 2022-001 ? Suspension and Debarment Information on the federal program: Federal Agency: Various Assistance Listing: Various; Research and Development Cluster Award Year: 2022 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and debarment -party vendor searches, the third party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford?s compliance department to ensure that there are no findings that would be of concern to Sanford?s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) Report and therefore did not provide this level of report to Sanford. To provide context on scale of vendors subject to suspension and debarment, Sanford paid a total of 27,000 vendors in 2022. There were three vendors identified through the vendor setup and monitoring process to be suspended or debarred. None of those vendors were associated with the programs funded with federal funds. Sanford?s preventative and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendor is effectively mitigated through existing preventative and detective internal controls. Sanford will document a periodic validation of the suspension and debarment search results performed by the third-party vendor for vendor searches that yield no suspension and debarment match. In addition, Sanford will enhance its procedural documentation regarding retention of evidence related to reconciliation of vendor list when discrepancies are identified and the suspension and debarment results that is generated through the vendor setup process. Responsible official: Tracy Sattler, Director of Compliance and Melanie Paape, Executive Director of Supply Chain Anticipated completion date: August 31, 2023

View Audit 34025

Finding 39497 (2022-001)

Significant Deficiency 2022

Population Services International

DC

Subrecipient Monitoring § 200.303 § 200.328

2022-001 Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Marcie Cook, Susan Mukasa Title: Vice Presidents, Global Operations Phone Number: 202 753 7532 / 202 734 7784 Estimated Completion Date ? ongoing ...

2022-001 Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Marcie Cook, Susan Mukasa Title: Vice Presidents, Global Operations Phone Number: 202 753 7532 / 202 734 7784 Estimated Completion Date ? ongoing Corrective Action PSI will focus on continuous improvements to the reporting tracking system (D-Tracker) that ensures each contract has a clear program and financial reporting deadlines. The Program Management Team will keep working with Project Directors to confirm accuracy of the report deadlines in D-Tracker. Quarterly reports will be run to confirm upcoming reports due in the quarter and be shared with appropriate staff to ensure that deadlines are met or approvals to extend due dates are appropriately documented. Training will be provided throughout the year so that monitoring is part of the standard procedure.

View Audit 46560

Finding 39427 (2022-002)

Significant Deficiency 2022

Avera Health

SD

Internal Control / Segregation of Duties § 200.303

Finding 2022-002 Department of Health and Human Services CFDA #93.461 COVID-19 Uninsured COVID Testing and Treatment Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance and Noncompliance Finding Summary: Our testing over activities allowed and allowable...

Finding 2022-002 Department of Health and Human Services CFDA #93.461 COVID-19 Uninsured COVID Testing and Treatment Activities Allowed and Allowable Costs Significant Deficiency in Internal Control over Compliance and Noncompliance Finding Summary: Our testing over activities allowed and allowable costs identified three instances in which patient treatment charges were charged under federal award and COVID-19 was not the primary diagnosis. Responsible Individuals: Mary Wickersham, Amanda Schutz Corrective Action Plan: The Organization will review and strengthen the controls surrounding evaluation of diagnosis codes to include ?Z diagnosis codes? prior to the submission of claims. The Organization has since issued refunds to the federal agency related to the instances noted in the finding. Anticipated Completion Date: June 30, 2023

View Audit 34520

Finding 39213 (2022-002)

Material Weakness 2022

City of Maitland

FL

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

Name of Contact Person: Jerry Gray, Finance Director Corrective Action: The City will implement a process to ensure all grant reports are reviewed by a second reviewer prior to submission. Proposed Completion Date: Immediately.

View Audit 37097

Corrective Action Plans

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