Corrective Action Plans

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Finding 2022-001 Condition: The System did not complete the PRF Period 3 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System inadvertently entered fiscal year Q1 and Q2 for Total Revenue/Net Charges from Patient Care (2022 Actuals) instead of calendar y...
Finding 2022-001 Condition: The System did not complete the PRF Period 3 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System inadvertently entered fiscal year Q1 and Q2 for Total Revenue/Net Charges from Patient Care (2022 Actuals) instead of calendar year Q1 and Q2. There was no impact on the lost revenues calculation as neither quarter had lost revenues. Corrective Action Plan: Corrective Action Planned: Cabell Huntington Hospital, Inc. and Subsidiaries agrees with the finding and has worked extensively over the past several years to monitor the changing guidelines surrounding the various programs designed to respond to the COVID-19 pandemic. Management will continue to further this effort by reading all available guidance to ensure that the most recent guidelines are followed. Additionally, management has begun the process of reviewing policies and procedures to improve internal controls over the submission of PRF reports, including implementing controls sufficient to identify and correct errors prior to the completion of PRF reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: D. Monte Ward, Senior VP/CFO 1340 Hal Greer Blvd Huntington, WV 25701 Phone 304.526.2055 Monte.ward@mhnetwork.org Anticipated Completion Date: June 30, 2023
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summa...
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: As mentioned above in Finding 2022-002 a policy was developed on October 14, 2022, and has been followed since that date. For the Provider Relief Fund reporting #4 Option iii was chosen in March 2023. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted in March 2022. Anticipated Completion Date: The new policy was created in October 2022 and the correct selection of Option iii for PRF reporting #4 was completed in March 2023.
Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summa...
Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District?s lost revenue calculation claimed under the Provider Relief Fund program and the HHS reported submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: A policy was developed on October 14, 2022, outlining the controls to be followed for filing reports with Federal Agencies. This policy reflects the procedures needed for proper internal controls to provide assurance that the District is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. All reporting after the creation of the policy has followed the policy. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted. Anticipated Completion Date: Completed October 14, 2022 2
Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described ab...
Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described above. The ISMMS Office of Student Financial Services has implemented a combined monthly reconciliation and drawdown process that identifies and resolves discrepancies, as required by the U.S. Department of Education?s Direct Loan reconciliation guidelines under 34 CFR 685.300(b)(5). The process will be detailed in the School?s procedure manual and staff will be trained accordingly. With this new process in place, we will be compliant with the U.S. Department of Education regulations. Name of responsible official: LaVerne Walker Director of Student Financial Services laverne.walker@mssm.edu Projected completion date: ? September 26, 2023: Completed implementation of combined monthly reconciliation and drawdown process ? December 31, 2023: Completed staff training sessions and revision to procedure manual
Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program ...
Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program Name: HIV Emergency Relief Project Grants ? Grantor: Department of Health and Human Services (HHS) ? Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to implement effective internal controls regarding 1) Review and retention of income and residency verification at program Intakes, and 2) Real time documentation of participants? income and residency eligibility at the required frequency (typically during 6 month Reassessments) with accepted supporting documentation for each participant. 3) This documentation will be entered into our EMR (EPIC) for each patient, outlining our eligibility verifications done at Intakes, Reassessments or Reassessment Attempts, along with screen shots from ePACES and/or other eligibility documents used. This will enable our program team and our funders and auditors to be able to more easily review our documented ongoing program eligibility for each patient. This will also improve our quality controls and will enable program staff to more effectively monitor annual eligibility checks. Contact person: Diane Tider Expected Completion Date: Implementing immediately 10/2/23
FINDING 2022-004 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, if there was not a problem with the finances of this grant could this not have been a comment. There is not any one of u...
FINDING 2022-004 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, if there was not a problem with the finances of this grant could this not have been a comment. There is not any one of us involved with this grant that would have known about the prevailing wages part of it. Description of Corrective Action Plan: Projects requiring prevailing wage are complete, so we can't change this one, but will review grant agreements and try to remember to ask grantor if prevailing wage applies if any new grants are received, so we can develop controls and monitor compliance. Anticipated Completion Date: 02/27/2023
FINDING 2022-003 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, we were not aware that these funds participated in the public transfer. We know Title I does and we communicate with the...
FINDING 2022-003 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, we were not aware that these funds participated in the public transfer. We know Title I does and we communicate with the other schools but we were not informed about ESSER I following these guidelines. Again, we will probably not receive these grants again and I feel they could have been comments instead of findings. Description of Corrective Action Plan: I can?t do anything about this but if we receive money like this again I will make sure and ask about the public transfer. Anticipated Completion Date: 02/27/2023
FINDING 2022-002 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, these documents were reported by more than one person I just forgot or didn?t think about having someone sign off on it....
FINDING 2022-002 Contact Person Responsible for Corrective Action: Trina Huff Contact Phone Number:812-689-4114 Views of Responsible Official: We concur with the finding; however, these documents were reported by more than one person I just forgot or didn?t think about having someone sign off on it. Again, we will probably not receive these kinds of grants again and something this simple could be a comment and not a finding. I feel that if there are no issues with the actual funding and finances that it could be a comment. Description of Corrective Action Plan: I will document who helped with their portion of the report and have them sign off on it. Anticipated Completion Date: 02/27/2023
The City has established an Audit Review Certification form that will be completed by employees to formally document the review of subrecipient agencies? audit reports.
The City has established an Audit Review Certification form that will be completed by employees to formally document the review of subrecipient agencies? audit reports.
The City has established an Audit Review Certification form that will be completed by employees to formally document review of subrecipient agencies? audit reports.
The City has established an Audit Review Certification form that will be completed by employees to formally document review of subrecipient agencies? audit reports.
The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of re...
The City will establish the following procedures to ensure payment requests received from subrecipients are paid within 30 days of receipt of a complete request for reimbursement: 1. Department of Human Service Programs (DHSP) Contract Manager reviews invoices within 5 business days of receipt of request for reimbursement from subrecipient. a. If invoice is complete, original date of receipt is recorded. b. If invoice is incomplete, subrecipient is notified of items or documentation that is missing and receipt date is updated to reflect date of receipt of complete invoice. 2. Contract Manager approves payment request and submits to DHSP Fiscal staff for processing. 3. Fiscal staff processes and submits to Auditing Department as Priority payment.
The City will update the subrecipient contract template to ensure the required language is included in all newly executed contracts certifying that the agency, its officers, and employees are not suspended or debarred from doing business with the federal government. Prior to entering into contracts ...
The City will update the subrecipient contract template to ensure the required language is included in all newly executed contracts certifying that the agency, its officers, and employees are not suspended or debarred from doing business with the federal government. Prior to entering into contracts with subrecipients, the City will check that each subrecipient is not included on the SAM.gov Exclusion List and will include a dated screenshot from the SAM.gov website documenting the review in each project file.
Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and has implemented procedures to ensure appropriate documentation of personnel costs are complete and accurate. Coordination with Payroll staff begin and was validated wi...
Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and has implemented procedures to ensure appropriate documentation of personnel costs are complete and accurate. Coordination with Payroll staff begin and was validated with current pay period ending 9/23/23. Hourly staff are clocking into appropriate cost center and salaried staff are submitting hours to payroll to ensure appropriate time tracking Contact Person(s): Heather Hintz/Kathy Dams Anticipated Completion: 12/31/2023
Finding 20511 (2022-001)
Significant Deficiency 2022
Corrective Action Plan: Carle to proceed with publishing and implementing its Sub-Recipient Monitoring Policy. The Grants Administration Office has already created Sub-Recipient Orientation training session for Carle departments and prospective subrecipients and will work with Compliance to active...
Corrective Action Plan: Carle to proceed with publishing and implementing its Sub-Recipient Monitoring Policy. The Grants Administration Office has already created Sub-Recipient Orientation training session for Carle departments and prospective subrecipients and will work with Compliance to actively train stakeholders. Contact Person(s): Kathy Dams, Director, Grants Administration and Research Operations Anticipated Completion: 12/31/2023
FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disburseme...
FINDING 2022-002 Contact Person Responsible for Corrective Action: Scott Finley Contact Phone Number: 812-526-3511 Contact E-mail: sfinley@edinburgh.in.us View of responsible official: The town concurs with the Section III finding identified. Description of Corrective Action Plan: For SRF disbursements related to construction, the town?s engineers review the pay applications and are sent to the town for review. The pay app is submitted to the council for review and approval. Upon approval, the Clerk-Treasurer signs the pay app and submits it to SRF for disbursement. Moving forward, the town council president will sign the pay app rather than the Clerk-Treasurer. For SRF Disbursements related to engineering, the invoice is reviewed by the Town Manager and Clerk- Treasurer and then submitted to SRF for disbursement. Moving forward, these invoices will be processed similarly to the construction pay apps. These invoices will be reviewed by the Town Manager and Clerk- Treasurer and then submitted to the council for approval. After council approval they will be submitted to SRF for disbursement. The town will also request that the engineers add a signature page to their invoices so they can be signed off on. Anticipated Completion Date: Process will be implemented immediately.
Existing processes were revised to ensure all billings to the HRSA uninsured program were in compliance with federal guidelines and regulations. Additionally, management established a work group to review inpatient accounts incorrectly billed to HRSA to ensure the amounts are properly refunded.
Existing processes were revised to ensure all billings to the HRSA uninsured program were in compliance with federal guidelines and regulations. Additionally, management established a work group to review inpatient accounts incorrectly billed to HRSA to ensure the amounts are properly refunded.
View Audit 22522 Questioned Costs: $1
Item 2022-001 ? Special Tests and Provisions ? Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Feder...
Item 2022-001 ? Special Tests and Provisions ? Wage Rate Requirements Recommendation: 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? 2 CFR 200.326 and 29 CFR Part 5, Labor Standards Provisions Applicable to Contracts Governing Federally Financed and Assisted Construction (DOL Regulations) require the contractor or subcontractor to submit to the nonfederal entity weekly, for each week in which any contract work is performed, a copy of the payroll and a statement of compliance (certified payrolls). We recommend the strengthening of controls to ensure the prevailing wage rate clauses are included in the contracts and that certified payrolls are received for each week in which construction work is performed. The Chief School Financial Officer, Linda Harper, should review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She should also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed. Action Taken: Management has reviewed the requirements of 2 CFR Section 200.303 and 2 CFR 200.326 relating to wage rate requirements and agrees with the recommendation. Management has already communicated with all contractors and subcontractors regarding the wage rate requirements and has implemented additional procedures, effective January 1, 2023, stating that the Chief School Financial Officer, Linda Harper, will review documentation for inclusion of the prevailing wage rate clauses in construction contracts as part of the bid process prior to expenditures being made. She will also review all invoices received from contractors and subcontractors to ensure that the certified payroll information is received for all weeks for which construction work is performed.
Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: UMH did set aside a reserve amount within a saving account; however, the funds were not segregated in a separat...
Finding 2022-005 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: UMH did set aside a reserve amount within a saving account; however, the funds were not segregated in a separate bookkeeping account or bank account. Additionally, UMH entered into three debt arrangements during the fiscal year with a financial institution without obtaining prior written consent from the agency. Responsible Individuals: Melissa Gale, CEO; Erin Odens, CFO Corrective Action Plan: LJMH will have the USDA reserve money segregated as a separate line item in the financials. LJMH did submit proper information to the USDA for the three loans that were entered into without consent and USDA did reply back with post-loan approval concurrence. Future loans will be approved through the USDA prior to entering into them. Anticipated Completion Date: March 1, 2023
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Audited financial statements were submitted to USDA prior to review and approval from Board of Directors. Resp...
Finding 2022-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Audited financial statements were submitted to USDA prior to review and approval from Board of Directors. Responsible Individuals: Melissa Gale, CEO; Erin Odens, CFO Corrective Action Plan: For the current year a waiver was obtained from the USDA acknowledging that the financial statements were not approved from Board of Directors. Going forward the audit will need to be completed and approved by the Board of Directors prior to submission to the USDA. Anticipated Completion Date: February 1, 2023
Federal Grantor: US Department of Transportation, Federal Transit Administration, Federal Transit Formula Grants, Direct Award, All Award under Assistance List (AL) Number 20.507 Effect: Expenses were misallocated to individual routes and purposes, resulting in an overclaim of Woodland preventative ...
Federal Grantor: US Department of Transportation, Federal Transit Administration, Federal Transit Formula Grants, Direct Award, All Award under Assistance List (AL) Number 20.507 Effect: Expenses were misallocated to individual routes and purposes, resulting in an overclaim of Woodland preventative maintenance expenses of $12,268 under grant CA-2022-204. Auditor Recommendation: We recommend the District develop written procedures for allocating expenses to routes and purposes used to claim expenses under federal grants, including what data should be input into the allocation spreadsheet, the formulas used to allocate each type of expense to routes, which expenses should be allocated to each route and purpose (operating, preventive maintenance, etc.) and which expenses may not be allocated to certain routes and purposes. A summary tab should be added to the spreadsheet to sum amounts for each route computed on separate tabs on the spreadsheet to make it easier to reconcile total operating expenses, preventive maintenance, insurance, communications and other expenses to the general ledger. The District should also contact the FTA to discuss how to address the $12,268 amount overclaimed. YCTD Contact Person Responsible for the Corrective Action: Leo Levenson, Inteirm CFO, Llevenson@yctd.org. Management Response and Corrective Action Plan: YCTD concurs with the finding and recommendation. YCTD has already contacted the FTA regional office and followed their guidance on how to return the $12,268 amount overclaimed. YCTD will formalize new written procedures and summary spreadsheet tabs as recommended by the auditor, with a target date for completion of March 31, 2023.
Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B reve...
Finding 2022-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Hospital did not properly include 340B revenues and final audit adjustments in net patient service revenue. In addition, the Hospital did not properly report payor categories for quarters in which the net patient service revenues were negative. Responsible Individuals: Patti Clavette, Chief Financial Officer; Jackie Lundblad, Chief Executive Officer Corrective Action Plan: Management will modify the lost revenue reported on future reports, if any, to reflect an accurate total lost revenue amount. In addition, a formal review and approval process will be implemented to ensure calculations are in accordance with applicable requirements and a member of management will be identified to review all reporting requirements for federal grants and awards to ensure the Hospital is in compliance with the requirements. Anticipated Completion Date: September 30, 2023
Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests an...
Management has implemented procedures to verify that the expenditures that are requested for reimbursement are not duplicated and are allowable under the Uniform Guidance. Review procedures have been added to help ensure that only allowable salaries expenses are included in reimbursement requests and that all voided checks are omitted.
View Audit 19855 Questioned Costs: $1
Finding 20377 (2022-001)
Significant Deficiency 2022
As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. A...
As noted within the portal filing summary for the general reporting Period 1, the Corporation?s consolidated lost revenue totaled $141,363,926. Payments from the PRF for Period 1 totaled $53,982,121 for the consolidated parent and $14,810,675 for St. John?s Medical Center Period 2 targeted report. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the reporting error identified and described in the ?condition found? section above. Therefore, management believes no repayment of PRF funds received would be required. Management is implementing a process to add additional review steps prior to finalizing future reporting submissions.
2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited st...
2022-003 Material Weakness in Internal Control over Compliance with Activities Allowed or Unallowed and Allowable Costs/ Cost Principles Condition: The Organization did not retain the required documentation to support the review of expenditures. Cause: The Organization had turnover and limited staffing available. Management?s Response and Corrective Action Plan: Changing the personnel involved has solved much of the problem, also the full awareness of what needs to be retained has also been explained to management. If/ when funds from federal sources are used, those expenditures will be reviewed monthly. Specifically, this will mean: ? Maintain EIDL-sourced funds in separate bank/ account. ? Have single authorization for any movement/ usage of funds in EIDL account. ? If/when funds from EIDL are used, have a written statement for purpose and documentation produced for use at the time of request. Responsible Individuals: ? Maintain separate account ? Marcia Meyer, CEO, in conjunction with Board Finance Committee ? Authorization for use of funds ? Marcia Meyer ? Maintenance of records for use ? JC Thompson ? Confirmation with use of funds per allowable uses per national guidelines ? Jennie Myers ? Reporting on monthly finance report ? Jennie Myers Anticipated Completion Date: This process is underway and will be visible at the fiscal year-end audit in June 2023.
Finding 20316 (2022-001)
Significant Deficiency 2022
The Guthrie Clinic and Affiliates Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001: Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVlD-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition/Context. In th...
The Guthrie Clinic and Affiliates Corrective Action Plan For the Year Ended June 30, 2022 Finding 2022-001: Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVlD-19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition/Context. In the Corporation's Period 2 submission, using the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3), the lost revenues for quarter 4 of 2020 were incorrectly reported as $0 (rather than $4,934,624) and the lost revenues for quarter 1 of 2021 were incorrectly reported as $4,934,624 (rather than $0). This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation has implemented additional internal controls through independent review and sign off of the draft PRF reporting, prior to final submission, to ensure completeness and accuracy. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO -Guthrie Hospitals Anticipated Completion Date: This was corrected in the Period 3 submission filed on September 30, 2022
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