Corrective Action Plans

Finding 51204 (2022-011)

Significant Deficiency 2022

State of Delaware

DE

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303 § 200.317

Reference Number: 2022-011 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance ...

Reference Number: 2022-011 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Department of Health and Social Services State Division Name: Division of Social Services Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ? 12/31/2024) SLFRP2629 (3/3/2021 ? 12/31/2024) Compliance Requirement: Procurement, Suspension & Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance controls and procedures to ensure that it follows the State?s procurement policy and Federal suspension and debarment regulations for all goods and services charged to the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the auditor?s recommendation. Ongoing meeting, training, and monitoring have helped and will continue to help DSS staff to achieve compliance. The following actions have been taken to improve the Procurement process. ? Program unit staff will receive Procurement Bootcamp training on contract rules. ? Program unit & Fiscal unit staff will monitor and track all contracts, MOU/MOA?s and agreement so they are in compliance with State Procurement policy. ? Fiscal unit will ensure they have an approval to pay for any invoices. ? Conduct monthly meetings with OSEC CMP Managers and DSS Fiscal unit. Name(s) of the contact person(s) responsible for corrective action: Thomas Hall, DSS Director Victor Ting, DSS Chief of Administration Janneen Boyce, DSS Policy, Social Service Chief Administrator Joanne Sunga, DSS Fiscal, Social Service Chief Administrator Planned completion date for corrective action plan: ? Procurement Bootcamp training was completed March 22, 2023. ? Procurement monitoring, ongoing. ? Fiscal approval workflow, ongoing. ? Monthly Procurement meeting, ongoing.

View Audit 43524

Finding 51203 (2022-010)

Material Weakness 2022

State of Delaware

DE

Subrecipient Monitoring § 200.303

Reference Number: 2022-010 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Office of the Governor Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ?...

Reference Number: 2022-010 Prior Year Finding: No Federal Agency: U.S. Department of the Treasury State Department Name: Office of the Governor Federal Program: COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number and Year: SLFRP0139 (3/3/2021 ? 12/31/2024) SLFRP2629 (3/3/2021 ? 12/31/2024) Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Office should enhance its procedures and internal controls regarding preparation of the Project and Expenditure Reports to ensure that information reported is accurate and agrees to supporting documentation. We further recommend that the Office work with State agencies which incur costs under the program to develop procedures and controls to ensure that they provide accurate information to the Office on a timely basis to facilitate timely and accurate project reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding but here is our explanation. The American Rescue Plan State and Local Fiscal Recovery Funds are awarded in advance to our subrecipients based on language in each subrecipient agreement. Within United States Treasury?s reporting portal, we are required to report subawards for each subrecipient and related expenditures and programmatic details. We made the decision to report subrecipient activity for each subaward based on the quarterly data provided to our team. For instance, a subrecipient awarded $50,000 with quarterly expenditures of $10,000 were reported as expending $10,000 on the quarterly UST Project and Expenditure report. This decision was made because it most accurately accounted for the status of a project and the utilization of the funding. This approach resulted in a discrepancy between the expenses in FSF and the UST reporting. Based on guidance from CLA, coming out of the single audit, our team will be reporting the subrecipient activity as the amount paid to each, not based on the expenses of their subaward. A subrecipient awarded and paid $50,000 will be reported as an expenditure of $50,000. We will continue to track and capture subrecipient utilization of the funding through compliance monitoring and quarterly updates. The previously reported amounts in U.S. Treasury?s system will be adjusted for the quarter ending March 31, 2023. This action will resolve CLA?s reporting finding. CLA will test the 3/31/23 and 6/30/23 reports during next year?s single audit to ensure the finding was corrected.

View Audit 43524

Finding 51196 (2022-009)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-009 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-009 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Division review and enhance procedures and controls to ensure that it retains documentation for claimant eligibility and that benefit payments are accurate in accordance with program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will continue to utilize and enhance of customer service management tools and centralize where documentation is retained. We will continue to review program requirements and ensure they are reviewed, and implemented, and processed correctly. We will review and ask for clarity regarding UIPLs when there is a discrepancy. We are also looking to modernization our systems to house all our documentations. Name(s) of the contact person(s) responsible for corrective action: Shannon Lolley ? UI Administrator Planned completion date for corrective action plan:

View Audit 43524

Finding 51195 (2022-008)

Significant Deficiency 2022

State of Delaware

DE

Questioned Costs Reporting Significant Deficiency § 200.303

Reference Number: 2022-008 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor ` Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Yea...

Reference Number: 2022-008 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor ` Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 9130, Financial Status Report, UI Programs Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: We recommend the Division review and enhance procedures and internal controls to ensure that ETA 9130 reports are submitted accurately and that they tie to supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal department has added to our Policy and Procedures the terms of the reporting period being 45 days after then end of the quarter. It was also posted on a group calendar to begin work on the reports at 30 days after quarter end. Name(s) of the contact person(s) responsible for corrective action: Laurie Wexler Planned completion date for corrective action plan: 01/03/2023

View Audit 43524 Questioned Costs: $1

Finding 51184 (2022-007)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-007 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 9050 - Time Lapse of All First Payments except Workshare Report Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance procedures and internal controls to ensure that ETA 9050 reports are submitted timely, by the 20th of the month following the month to which the data relates. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DE has put a process in place to monitor and track the progress and timeliness of all ETA reporting. Auto-reminders will be created to notify all units responsible for ETA reports two weeks before the due date. Name(s) of the contact person(s) responsible for corrective action: Marie Cameron Planned completion date for corrective action plan: Timeliness Issue corrected. The ETA 9050 has been submitted timely for the months following 12/31/2021, except for the report period 07/31/2022. Auto reminders will be completed by 4/15/2023

View Audit 43524

Finding 51183 (2022-006)

Significant Deficiency 2022

State of Delaware

DE

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

Reference Number: 2022-006 Prior Year Finding: 2021-003 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17...

Reference Number: 2022-006 Prior Year Finding: 2021-003 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Reporting ? ETA 2208A, Quarterly UI Above-Base Report Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: The Division should review and update its reporting procedures and controls to ensure that ETA 2208A ? Quarterly UI Above-Base Reports are submitted no later than 30 days after the end of each quarter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Fiscal department has added to our Policy and Procedures the terms of the reporting period being 30 days after then end of the quarter. It was also posted on a group calendar to begin work on the reports at 20 days after quarter end. Name(s) of the contact person(s) responsible for corrective action: Laurie Wexler Planned completion date for corrective action plan: 01/03/2023

View Audit 43524

Finding 51182 (2022-005)

Material Weakness 2022

State of Delaware

DE

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Reference Number: 2022-005 Prior Year Finding: 2021-005 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17...

Reference Number: 2022-005 Prior Year Finding: 2021-005 Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Special Tests and Provisions ? Employer Experience Rating Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: The Division should review and enhance procedures and controls to ensure that employer experience rates are properly calculated and applied. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MERIT rating was completed on a Emergency Rule due to COVID 19 pandemic. Mainframe system required manual intervention to complete this special law. DOL does not consider the rate the employer places on the UC8 tax form only the rate assessed. The accounts that were incorrect were a result of the special rule and needed constant manual intervention. Should an overpayment occur DOL notifies employer of credit and allows them to utilize that on future quarterly payments. If the credit cannot be used we issue a check for the refund. DOL Staff created Emergency Rule 21 changing the tax table to correct the mainframe issue. Name(s) of the contact person(s) responsible for corrective action: Laura Henderson Planned completion date for corrective action plan: Resolved

View Audit 43524

Finding 51181 (2022-004)

Material Weakness 2022

State of Delaware

DE

Special Tests & Provisions Procurement, Suspension & Debarment Material Weakness § 200.303

Reference Number: 2022-004 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 A...

Reference Number: 2022-004 Prior Year Finding: No Federal Agency: U.S. Department of Labor State Department Name: Department of Labor State Division Name: Division of Unemployment Insurance Federal Program: Unemployment Insurance, COVID-19 ? Unemployment Insurance Assistance Listing Number: 17.225 Award Number and Year: UI340502055A10 (10/1/2019 ? 12/31/2022), UI347072055A10 (4/1/2020 ? 6/30/2023), UI372152255A10 (10/1/2021 ? 12/31/2024) Compliance Requirement: Special Tests and Provisions ? UI Benefit Payments Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation We recommend the Division review and enhance procedures and controls to ensure that BAM case investigations are completed timely in accordance with the time limits established in the ET Handbook No. 395. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. The BAM Unit experienced high turnover volumes during the pandemic, creating a backlog of UI Benefit investigations. The pandemic also changed the workforce dynamic, creating a culture of fully remote jobs in many job markets, which left most State agencies struggling to fill positions; because of this, State Government lost its competitive edge as an employer, resulting in low applicant response to job postings. It took the BAM unit several job reposting?s to get vacancies filled. However, we have filled most of the vacancies and will conduct interviews on Friday, 03/24/23, to fill the remaining two vacancies in the unit. We also recently made a change to our training strategy. There will be consecutive weeks of training in a classroom setting, along with OTJT. The BAM unit also assigns all available NASWA training to new hires during their first weeks of employment. We chose this training strategy to provide all new hires with consistent training to ensure understanding of the BAM investigative process. In addition, we will be hiring a Sr. accountant who will focus on all backlog items only. We are also in the process of converting all paper-driven methods to fully electronic ones. All BAM employees will receive the necessary tools, training, and work-from-home equipment for working successfully from home, allowing us to maintain production in case of another catastrophic event. Name(s) of the contact person(s) responsible for corrective action: Edward Gregware, Ann Marie Vanderhout, and Marie Cameron Planned completion date for corrective action plan: The management team is working on a plan to resolve all case investigation backlogs. We will be hiring a Sr. Accountant who will focus solely on backlogged cases. We now have three QC BAM auditors and will be hiring a fourth. Once fully trained, all BAM auditors will be assigned 7 cases weekly to complete within 45 days to ensure we meet the time frames established in the ETA Handbook No. 395. An auditor takes approximately 3 to 6 months to train and operate independently. At a minimum, it will take around 12 to 18 months to get new hires properly trained and backlogs resolved.

View Audit 43524

Finding 51177 (2022-003)

Significant Deficiency 2022

State of Delaware

DE

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Reference Number: 2022-003 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Department Name: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559, 10.582 Award Number and Year: 1DE303301 (10/1/2020 ? 9/30/2022) ...

Reference Number: 2022-003 Prior Year Finding: No Federal Agency: U.S. Department of Agriculture State Department Name: Department of Education Federal Program: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.559, 10.582 Award Number and Year: 1DE303301 (10/1/2020 ? 9/30/2022) Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Department should ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls are sufficient to ensure that the suspension and debarment status is verified for all subrecipients prior to issuance of the subawards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Delaware Department of Education (DDOE) Nutrition Team will update the online School Nutrition application to include a certification statement similar to the statement below. Have any current principal staff been debarred, suspended, proposed for debarment, declared inelligible, or voluntarily excluded from participation in this transaction by any Federla department or agency. Yes/No The DDOE Nutrition Team will check SAM exclusions on sam.gov until the application is updated. Name(s) of the contact person(s) responsible for corrective action: ? Jeremy Coleman, Support Staff ? Marianne Bernardi, Support Staff Planned completion date for corrective action plan: April 28, 2023

View Audit 43524

Finding 51112 (2022-001)

Significant Deficiency 2022

Olivet Nazarene University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility § 200.303

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than t...

The University understands the importance of accurate verification. It was missed by the verification specialist, and not a matter of process. The specialist simply missed the line on the tax document that listed the education credits. This caused the student to receive $200 less Pell funding than the eligibility. The student should have received $200 in additional Pell Grant funds, so the school contacted the student and applied $200 in university funding to offset that loss. On November 21st, Tim Schultz (verification specialist) was instructed about this important process. The Executive Director of Student Finance, Tiffany McCann, will help monitor those verification materials and process, which should reduce the chances of a repeat mistake and ensure compliance.

View Audit 42623

Finding 51108 (2022-008)

Material Weakness 2022

City of Thomasville Alabama

AL

Reporting § 200.303

Management agrees with the finding. The City will implement additional review procedures over grant reporting requirements, including reports prepared by third party grant administrators. The City Clerk will facilitate a timely review of all such reports.

View Audit 51068

Finding 51107 (2022-002)

Significant Deficiency 2022

Henry J. Austin Health Center, Inc.

PA

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

Views of Responsible Officials: The Center has implemented new Grant and Payment Management System (PMS) reconciliation workbooks to track grant expenditures. The Center also engages with consultants to assist with proper reporting and timely filing to avoid audit adjustments. In addition, the Stand...

Views of Responsible Officials: The Center has implemented new Grant and Payment Management System (PMS) reconciliation workbooks to track grant expenditures. The Center also engages with consultants to assist with proper reporting and timely filing to avoid audit adjustments. In addition, the Standard Operation Procedures will be updated to ensure that an appropriate protocol and controls for reviewing and approval of documentation prior to submission are in place. The Center will implement a plan that will include revision and approval from the Chief Financial Officer or designee prior to submission, required in the Payment Management System.

View Audit 51067

Finding 51069 (2022-003)

Significant Deficiency 2022

Blue Earth County

MN

Questioned Costs Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.326

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has...

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has met with the IT department to discuss federal procurement requirements and possible checklists. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

View Audit 49837 Questioned Costs: $1

Finding 50960 (2022-001)

Material Weakness 2022

City of New Albany

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number: 812-948-5333 Views of Responsible Official: Concur With Finding Description of Corrective Action Plan: The City does not dispute the finding regarding suspension and disbarment as stated in the aud...

FINDING 2022-001 Contact Person Responsible for Corrective Action: Linda Moeller Contact Phone Number: 812-948-5333 Views of Responsible Official: Concur With Finding Description of Corrective Action Plan: The City does not dispute the finding regarding suspension and disbarment as stated in the audit. This is, unfortunately, a carryover from the 2021 audit which was not finalized and published till November 22, 2022. The city was aware during the finalization of the 2021 audit and discussed with auditors that this would be a problem for 2022 due to the timing of notification of the issue and the City?s inability to implement a corrective action for matters that occurred prior to November 22, 2022. The process for verification of suspension and disbarment was completed in late 2022/early 2023. Staff verifies prior to any recipient receiving funds that they are not federally suspended or disbarred from doing business at the federal level. A review of all recipients for 2022 confirmed that none of them had any issues with the federal suspension and disbarment requirement verification. The City rejects the classification of ?systemic? issues with SLRF funding and application of processes, but acknowledged the previous issues regarding suspension/disbarment as the only audited issue. As stated previously, the City implemented a process upon awareness of the finding and continues to follow it. A designated staff person verifies that any recipient of funds is not subject to suspension and/or disbarment for business at the federal level prior to any funding. Anticipated Completion Date: Done

View Audit 42127

Finding 50951 (2022-004)

Significant Deficiency 2022

Southwest Healthcare Services

ND

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

Finding Summary: Southwest completed the Provider Relief Fund reporting requirement without factoring in the amounts of expenses that were reimbursed by other sources. This specifically relates to the amount that Southwest was reimbursed by Medicare as a result of being a critical access hospital th...

Finding Summary: Southwest completed the Provider Relief Fund reporting requirement without factoring in the amounts of expenses that were reimbursed by other sources. This specifically relates to the amount that Southwest was reimbursed by Medicare as a result of being a critical access hospital that get reimbursed based on cost. Responsible Individuals: Dennis Goebel, Chief Executive Officer; Amanda Loughman, Chief Financial Officer. Corrective Action Plan: Management will ensure to factor in a portion of the Provider Relief Fund expenses that are being reimbursed by other sources when completing the reporting requirements. Anticipated Completion Date: 12/31/2023

View Audit 52761

Finding 50948 (2022-004)

Material Weakness 2022

McIntosh Senior Living

MN

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding 2022-004 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary The reserve account was not separately identified and there was no formal review separate from the preparer over t...

Finding 2022-004 Federal Agency Name Department of Agriculture Program Name Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary The reserve account was not separately identified and there was no formal review separate from the preparer over the reserve fund reconciliation. Responsible Individuals Sharlene Knutson, Administrator Corrective Action Plan We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documents. Anticipated Completion Date September 30, 2023

View Audit 52757

Finding 50946 (2022-001)

Significant Deficiency 2022

Piedmont Healthcare, Inc.

GA

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

Finding No. 2022-001 ? Activities Allowed and Unallowable/Allowable Costs Program: COVID -19 Provider Relief Fund Award Year: January 1, 2020 through June 30, 2022 (a) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over th...

Finding No. 2022-001 ? Activities Allowed and Unallowable/Allowable Costs Program: COVID -19 Provider Relief Fund Award Year: January 1, 2020 through June 30, 2022 (a) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. (b) Condition Found, Including Perspective During our test work, we selected a sample of 40 incentive bonus payments made during the fiscal year 2022 reporting period. We noted that PHC was unable to provide evidence of management review and approval for each of the incentive bonus payments sampled. These disbursements were made for allowable costs under the terms and conditions of the program. (c) Possible Cause PHC was unable to provide evidence of certain management reviews and approvals because the control was not designed to require the retention of documentation of management review at the transactional level. (d) Questioned Cost None. (e) Effect Evidence of the effective operation of management review controls was not maintained in accordance with Federal requirements. (f) Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. (g) Repeat Finding in the Prior Year Repeat of prior year Finding No. 2021-001. (h) Recommendation We recommend that PHC strengthen controls over the management review process to enhance the retention of evidence of management review and approval. (i) View of Responsible Officials Management concurs with the finding. While we believe appropriate controls exist relating to the management review and approval of allowable costs at the transactional level, we concur that procedures relating to obtaining and maintaining documentation of such reviews need to be strengthened. (j) Corrective Action Plan Management will ensure communication of the finding to the reviewers and submitters of allowable costs and revise procedures to ensure documentation of reviews and approvals is obtained and maintained. Prior to submitting allowable costs to Health Resources and Services Administration (?HRSA?), we will obtain documentation of the approval of these costs and maintain this documentation in the same manner as the documentation of the submission of the costs to HRSA. (k) Anticipated Completion Date Correction of corrective action anticipated by August 31, 2023. (l) Name of Person for Corrective Action Marie Gaffney, Vice President Corporate Finance: (470) 271-6007.

View Audit 53715

Finding 50945 (2022-001)

Material Weakness 2022

Garrett Regional Medical Center

MD

Questioned Costs Allowable Costs / Cost Principles Special Tests & Provisions § 200.303

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours we...

Finding 2022-001- Allowable Costs, Activities Allowed and Special Tests and Provisions Contact Person: Lori Dixon Management?s Response: GRMC management will implement the following processes/procedures as a result of the finding of the 2022 Single Audit. During the audit review, FEMA hours were found to be unallowable on sample patients treated for COVID. Management reviewed the findings and identified additional patients/hours not covered by other funding sources to replace the unallowed data totaling $8,550. Completion Date: The steps above will be completed by October 31, 2023.

View Audit 52431 Questioned Costs: $1

Finding 50944 (2022-004)

Significant Deficiency 2022

Meeker Memorial Hospital

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Financial Assistance Listing #93.498 Significant Deficiency Compliance Requirement: 2 CFR 200.303(a) establishes that the aud...

Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Financial Assistance Listing #93.498 Significant Deficiency Compliance Requirement: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Hospital is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure review and approval of the lost revenue calculation and report submitted to the Department of Health and Human Services for Period 4. Responsible Individuals: Nicole Siegner, CFO Status: Management will enhanced internal controls to ensure lost revenue calculations and reporting submissions to HRSA were reviewed by an individual other than the preparer and documentation of approval was maintained.

View Audit 51724

Finding 50869 (2022-005)

Material Weakness 2022

Union County/college Corner Joint School District

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

FINDING 2022-005 Subject: COVID-19 ? Education Stabilization Fund ? Reporting Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013...

FINDING 2022-005 Subject: COVID-19 ? Education Stabilization Fund ? Reporting Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425D Federal Award Numbers and Years (or Other Identifying Numbers): S425D200013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. For the first report, the amounts reported as expended did not agree to underlying expenditure records of the School Corporation. Per discussion with the Treasurer, the amount in the report included expenditures from outside of the reporting period, resulting in an overstatement of expenditures of approximately $28,000. Additionally, for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Description of Corrective Action Plan: The treasurer will prepare the grant reporting and have the deputy treasurer review and make any corrections to the information online prior to submission. Responsible Party and Timeline for Completion: Jennifer Blakely, Treasurer, and Debbie Blevins, Deputy Treasurer ? this corrective action will be implemented for all reporting requirements immediately following the audit in March 2023.

View Audit 53337

Finding 50862 (2022-004)

Material Weakness 2022

Union County/college Corner Joint School District

IN

Procurement, Suspension & Debarment School Nutrition Programs § 200.303

FINDING 2022-004 Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.533, 10.555, 10....

FINDING 2022-004 Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.533, 10.555, 10.559 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Program and Procurement and Suspension and Debarment compliance requirements. Context: The School Corporation utilizes a purchasing cooperative to procure its key vendors for food service costs, however in some cases the School Corporation will handle their own additional procurements outside of the purchasing cooperative. During the audit period, there were three vendors for which the School made purchases between $10,000 and $150,000, which fell under the small purchase method for federal and state procurement regulations. For the one vendor selected for testing, documentation was not presented to verify methods or rationale used to satisfy the procurement requirements, which require three quotes to be obtained prior to entering into a transaction. Additionally, the School Corporation was not able to provide verification that the vendor is not suspended or debarred. Description of Corrective Action Plan: The treasurer and food service director will work together to check suspension and debarment on any vendor receiving school funds in the amount of $25,000 and over. This information will be reviewed and checked at the beginning of each school year and as needed with new vendors. Responsible Party and Timeline for Completion: Jennifer Blakley, Treasurer and Jenny Dunning, Food Service Director ? this information was reviewed and printed from the SAM government website on 3/21/23 and will be kept by the food service director. This will be completed at the beginning of each school year and potential new vendors will be checked prior to becoming active.

View Audit 53337

Finding 50861 (2022-003)

Material Weakness 2022

Union County/college Corner Joint School District

IN

School Nutrition Programs Cash Management Material Weakness § 200.303

FINDING 2022-003 Subject: Child Nutrition Cluster ? Reporting Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Fede...

FINDING 2022-003 Subject: Child Nutrition Cluster ? Reporting Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY2021, FY2022 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: We noted that for one claim in a sample of four, there was no formal evidence of the sponsor claim reimbursement summary being reviewed by someone independent of who prepared the sponsor claim reimbursement summary prior to submission. Description of Corrective Action Plan: The food service director will have the treasurer, deputy treasurer, or an administrator review and sign off on the sponsor claim reimbursement summary prior to submission. Responsible Party and Timeline for Completion: Jenny Dunning, Food Service Director ? this will be implemented immediately following the audit in March 2023.

View Audit 53337

Finding 50849 (2022-003)

Significant Deficiency 2022

Twin Lakes School Corporation

IN

Questioned Costs School Nutrition Programs Allowable Costs / Cost Principles § 200.303

FINDING 2022-003 Information on the federal program: Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program, Fresh Fruits & Vegetables Program Assistance Li...

FINDING 2022-003 Information on the federal program: Subject: Child Nutrition Cluster ? Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program, Fresh Fruits & Vegetables Program Assistance Listing Numbers: 10.553, 10.555, 10.559, 10.582 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs/Cost Principles Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Allowable Costs/Cost Principles compliance requirements. Context: During testing of 10 payroll disbursements for allowable costs/cost principles, we noted there was one instance where the timecard for the Food Services employee displayed 79 total hours of normal pay and one hour of overtime for the two-week period. We reviewed the payroll distribution report for this time period and note that the employee was paid for 69.5 hours of normal pay and 10.5 hours of overtime. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will verify that the number of hours and pay rate per the payroll register agrees to the hours worked by the employee per their reviewed time sheet and their respective rate of pay. Responsible Party and Timeline for Completion: April 01, 2023

View Audit 52593 Questioned Costs: $1

Finding 50848 (2022-002)

Material Weakness 2022

Twin Lakes School Corporation

IN

Questioned Costs School Nutrition Programs Cash Management § 200.303

FINDING 2022-002 Information on the federal program: Subject: Child Nutrition Cluster Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program, Fresh Fruits & Vegetables Program Assistance Listing Numbers: 10.55...

FINDING 2022-002 Information on the federal program: Subject: Child Nutrition Cluster Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program, Fresh Fruits & Vegetables Program Assistance Listing Numbers: 10.553, 10.555, 10.559, 10.582 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the reporting compliance requirement. Context: We noted that for four claims in a sample of four, the meal counts were overclaimed for the month. We noted that in October 2020, the School Corporation had overclaimed lunches by 823 meals and breakfast by 512 meals, in April 2021, had overclaimed lunches by 210 meals and breakfast by 58 meals, in October 2021, had overclaimed lunches by 90 meals and breakfast by 632 meals, and in April 2022, had overclaimed breakfast by 984 meals and fresh fruits and vegetables by 114. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will verify that each claim has been reviewed by a secondary person for accuracy and that the claim agrees to underlying detail for meals served. Responsible Party and Timeline for Completion: April 01, 2023

View Audit 52593 Questioned Costs: $1

Finding 50841 (2022-002)

Significant Deficiency 2022

Switzerland County School Corporation

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.303 § 200.328

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department...

FINDING 2022-002 Information on the federal program: Subject: Education Stabilization Fund ? Internal Controls Federal Agency: Department of Education Federal Program: COVID-19 ? Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) to meet federal reporting requirements for ESSER grant awards and the GEER grant award. The first report was for the period of March 13, 2020 to September 30, 2020 and was due by January 21, 2021. The second report was for the period of October 1, 2020 to June 30, 2021 and was due by May 13, 2022. We noted for both reports that were submitted, there was no documented review by someone other than the preparer of the report to ensure the information submitted was complete and accurate. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. The School Treasurer will complete the Annual ESSER data report. The Grant Director will verify the report(s) for accuracy and completion. The Grant director will sign off on each report and then confirm via email the report(s) is correct and ready for submission to the IDOE. Responsible party and timeline for completion: Contact person responsible for Corrective Action: Patti Kappes, Treasurer Contact phone number: (812)427-4215 Anticipated completion date: April 30, 2023

View Audit 50941

Corrective Action Plans

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