Corrective Action Plans

Finding 571920 (2021-004)

Significant Deficiency 2021

Choctaw County

OK

Reporting Allowable Costs / Cost Principles § 200.303 § 200.502 § 200.508 § 200.510

We will adopt procedures and implement to ensure accurate reporting of expenditures on the SEFA and to ensure compliance with federal requirements.

View Audit 362988

Finding 571778 (2021-002)

Significant Deficiency 2021

Gunnison Valley Hospital Special Service District

UT

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Activities Allowed or Unallowed, Allowable Cost/Cost Principles Finding Summary: The District ...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: Provider Relief Fund and American Rescue Plan {ARP} Rural Distribution Compliance Requirement: Activities Allowed or Unallowed, Allowable Cost/Cost Principles Finding Summary: The District did not have adequate internal controls policy in place to ensure expenditures claimed were accurate and based upon underlying records and to ensure the records were retained to support the amounts. Responsible Individuals: Brian Murray, Chief Financial Officer Corrective Action Plan: GVH will review its internal controls related to grant tracking. It also assign a project or grant account number to each grant and code all expenditures to that account code. The items in this account will be logged and the appropriate back identified and maintained.

View Audit 362800

Finding 565787 (2021-013)

Material Weakness 2021

Rogers County

OK

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.403

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the ...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the state and local partners in each federal award to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. These policies and procedures will be designed to identify requirements for recipients and sub-recipients of grants, ensure accurate equipment and real property management, procurement, recipient and subrecipient monitoring and reporting. Further, policies will ensure a proper understanding of all grant requirements and compliance of the same.

View Audit 359478 Questioned Costs: $1

Finding 565786 (2021-012)

Material Weakness 2021

Rogers County

OK

Subrecipient Monitoring Internal Control / Segregation of Duties Equipment & Real Property Management § 200.303

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the ...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the state and local partners in each federal award to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. These policies and procedures will be designed to identify requirements for recipients and sub-recipients of grants, ensure accurate equipment and real property management, procurement, recipient and subrecipient monitoring and reporting. Further, policies will ensure a proper understanding of all grant requirements and compliance of the same.

View Audit 359478

Finding 565785 (2021-011)

Material Weakness 2021

Rogers County

OK

Subrecipient Monitoring Internal Control / Segregation of Duties Equipment & Real Property Management § 200.303

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the ...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with work with all elected officials and with the state and local partners in each federal award to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. These policies and procedures will be designed to identify requirements for recipients and sub-recipients of grants, ensure accurate equipment and real property management, procurement, recipient and subrecipient monitoring and reporting. Further, policies will ensure a proper understanding of all grant requirements and compliance of the same.

View Audit 359478

Finding 565784 (2021-008)

Material Weakness 2021

Rogers County

OK

Reporting Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.508 § 200.510

The Board of County Commissioners, with the cooperation and participation of all elected officials, rev iews, develops and implements policies and procedures to create a strong internal control environment. Addit ionally, the Board of County Commissioners conducts meetings with all elected officials...

The Board of County Commissioners, with the cooperation and participation of all elected officials, rev iews, develops and implements policies and procedures to create a strong internal control environment. Addit ionally, the Board of County Commissioners conducts meetings with all elected officials and officers responsible for the receipt and/or expenditure of county funds. These meetings address fiscal matters, including but not limited to, pol icy d iscussions and implementation, financial reports, budget oversight, SEF A reporting, and legal compliance. Policies and procedures, combined with fiscal oversight meetings, are intended to: I) prevent or detect material misstatements in the financial statements; 2) prevent or detect fraud within the county; 3) increase communication between the Board of County Commiss ioners and those elected officials and officers respons ible for the receipt and/or expenditure of public funds; 4) provide oversight over the fiscal concerns of the county; 5) identify and address risks related to financial reporting; 6) ensure the accuracy of Rogers County's financial statements, Estimate of Needs, the Schedule of Federal Awards ("SEFA"); and 7) ensure compliance with all applicable federal and state laws, regulations, and/or codes. The Board of County Commissioners, with the cooperation of all elected officials and officers responsible for the receipt or expenditure of county funds, will evaluate the processes and procedures currently in place to detect and identify material misstatements in Rogers County's financial statements, detect fraud, and identify and address risks related to Rogers County's financial processes and procedures will be implemented to identify fraud, detect material misstatements in the financial statements, and address risks related to financial reporting.

View Audit 359478

Finding 556180 (2021-006)

Material Weakness 2021

Island Health, Inc.

MA

Cash Management HUD Housing Programs Material Weakness § 200.302 § 200.303 § 200.305

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.

View Audit 354872

Finding 555673 (2021-006)

Material Weakness 2021

Island Health, Inc.

MA

Cash Management HUD Housing Programs Material Weakness § 200.302 § 200.303 § 200.305

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written proced...

Item 2021.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval proves, submission to the funding agency, and the recoding of the drawdown in the accounting system immediately after submission. • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence. • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail. • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices.

View Audit 354288

Finding 554491 (2021-012)

Material Weakness 2021

Washington County

OK

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

No corrective action taken.

View Audit 353149

Finding 554490 (2021-011)

Material Weakness 2021

Washington County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

No corrective action taken.

View Audit 353149

Finding 554489 (2021-010)

Material Weakness 2021

Washington County

OK

Reporting Internal Control / Segregation of Duties § 200.210 § 200.303 § 200.502 § 200.508 § 200.510

Through the assistance of the Oklahoma State Auditors and Inspectors Office, we have received appropriate instruction on how they wish the appearance of the SEF A to be. We believe this issue to be resolved and will be reported as instructed from this point forward.

View Audit 353149

Finding 530128 (2021-002)

Material Weakness 2021

Astria Health

WA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Mana...

Finding Number 2021-002: Reporting - Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance. Program: U.S. Department of Helath and Human Services - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution. Response and Corrective Action Plan: Management agress with the finding. The Organization will review and modify policies and procedures over Federal Grant Awards to ensure management implements policies and procedures to ensure there is understanding of the terms and conditions of Federal awards and that reports are prepared and reviewed by separate individuals with evidence of review documented. Anticipated Completion Date: by December 31, 2024. Responsible Person: Matthew Matthiessen, CFO.

View Audit 348226

Finding 526799 (2021-012)

Material Weakness 2021

Muskogee County

OK

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.403

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county comp...

Assistance Listing Number 21.019 Noncompliance Over Major Federal Program Coronavirus Relief Fund Activities Allowed or Unallowed and Allowable Costs/Cost Principles Chairman Board of County Commissioners: Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended within the allowable period of performance. It should be noted that OMES did not review any of the submitted information to determine eligibility prior to sending reimbursements for items that have now been determined questionable. County Clerk: Documentation was scanned into the Purchase Order's images and once the Purchase Order was paid, the images were then deleted by the Board of County Commissioners secretary. Images were later recovered by the software system and since the incident, restrictions have been implemented to no longer allow deletions.

View Audit 345861 Questioned Costs: $1

Finding 526798 (2021-011)

Material Weakness 2021

Muskogee County

OK

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

Assistance Listing Number21.019 Lack of Internal Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ens...

Assistance Listing Number21.019 Lack of Internal Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended.

View Audit 345861

Finding 524400 (2021-007)

Material Weakness 2021

Quileute Tribal School

WA

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

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: During the 2021 fiscal year there were superintendent vacancies. The School currently has a superintendent that is knowledgeable of this requirement. Implementation date: June 30, 2025

View Audit 343636

Finding 524399 (2021-006)

Material Weakness 2021

Quileute Tribal School

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff reports were not always documented or certified. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administrative positions are staffed. Training will be provided to staff responsible for Federal reporting. Implementation date: June 30, 2025

View Audit 343636

Finding 524397 (2021-005)

Material Weakness 2021

Quileute Tribal School

WA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.326

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: The School implemented an electronic procurement system. This system provides clarity with the documentation and approval of procurements. The transition from paper to digital formats will provide enhanced inte...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: The School implemented an electronic procurement system. This system provides clarity with the documentation and approval of procurements. The transition from paper to digital formats will provide enhanced internal controls to ensure that procurement transactions are documented and approved. Training will also be provided to staff involved with the procurement process to ensure that all are informed with the Federal and School requirements. Implementation date: June 30, 2025

View Audit 343636

Finding 524396 (2021-004)

Material Weakness 2021

Quileute Tribal School

WA

Equipment & Real Property Management Subrecipient Monitoring Material Weakness § 200.303 § 200.313

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential activities. The taking of physical inventories was not considered essential. Training relating to the Federal physical inventory requirements will be provided. A physical inventory will be completed in the 2024-2025 fiscal year. Implementation date: June 30, 2025

View Audit 343636

Finding 524394 (2021-003)

Material Weakness 2021

Quileute Tribal School

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Material Weakness § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff not all documentation and certifications were obtained. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administration departments are staffed. The School has implemented electronic procurement and timekeeping systems. These systems provide clarity in the approval process of procurement and timekeeping transactions. The transition from paper to digital formats provides enhanced internal controls to ensure that transactions are documented and approved. Training relating to the Federal and School procurement and timekeeping requirements will be provided. Implementation date: June 30, 2025

View Audit 343636

Finding 522673 (2021-018)

Material Weakness 2021

Ottawa County

OK

Procurement, Suspension & Debarment § 200.303

The county will work to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.

View Audit 341985

Finding 522473 (2021-010)

Significant Deficiency 2021

Saint Anthony Health Ministries and Subsidiaries

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.303

Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should inc...

Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures to ensure that documentation to evidence the operation of internal controls, such as supervisory reviews. The Corporation did not have sufficient documentation that internal controls were in place and operating effectively for control activities required for assessment of activities allowed or unallowed and for allowable costs/cost principles. The Corporation also did not have sufficient documentation that internal controls were in place and operating effectively for monitoring procedures required for cash management and reporting compliance requirements. Corrective Actions Taken or Planned: Due to turnover of key positions responsible for grant submission, supporting documentation that was kept on these individuals’ computers was not saved, passed on, nor stored in a central storage location so that the new hires that were brought in to replace these individual as well as others in the department could view them. In August 2023, the hospital has provided education and training to the staff regarding identifying documentation and files related to the annual SEFA as well as establishing a central departmental drive to store the documentations so that others can locate them when necessary. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.

View Audit 341736

Finding 520683 (2021-003)

Material Weakness 2021

Russellville Hospital, Inc.

AL

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness § 200.303 § 200.512

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task wi...

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 01/31/25.

View Audit 340379

Finding 517351 (2021-007)

Material Weakness 2021

Laporte County

IN

Internal Control / Segregation of Duties Material Weakness Period of Performance § 200.1 § 200.303

FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were...

FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were required to submit a one-time Interim report to the U.S. Department of the Treasury (Treasury). The County submitted the required interim report during the audit period. The County's process for the completion and submission of the Interim Report was that the County Auditor prepared the Interim Report based on the County's records, without a proper oversight or review process in place prior to submission. The Interim Report was determined to be materially misstated. The County understated the December 31, 2019, Base Year Revenues by $660,302. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct this finding, we will require one person to complete the report and another to review the report prior to submission. The preparer and reviewer will sign/initial to document the review process. Anticipated Completion Date: We will begin requirement a review prior to submission as of November 21, 2024.

View Audit 335349

Finding 517349 (2021-006)

Material Weakness 2021

Laporte County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

FINDING 2021-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order t...

FINDING 2021-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the procurement and suspension and debarment compliance requirement. Prior to entering into subawards and covered transactions with Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, recipients are required to verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded. Upon inquiring of the County to determine its policies and procedures related to suspension and debarment requirements for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, the County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on 100% of the applicable two vendors that were paid with SLFRF Funds. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct this finding, we will begin doing a search on sam.gov to find out if a vendor has been suspended or disbarred. We will also add language to bid and/or contracts to require vendors to supply proof of being in good standing with the federal government. Anticipated Completion Date: The above plan of action will begin on November 21, 2024.

View Audit 335349

Finding 517348 (2021-005)

Material Weakness 2021

Laporte County

IN

Procurement, Suspension & Debarment § 200.303

FINDING 2021-005 Finding Subject: Highway Planning and Construction - Procurement Summary of Finding: Material Weakness, Modified Opinion The County had not properly designed or implemented a system of internal controls that would be effective in preventing, or detecting and correcting, noncomplianc...

FINDING 2021-005 Finding Subject: Highway Planning and Construction - Procurement Summary of Finding: Material Weakness, Modified Opinion The County had not properly designed or implemented a system of internal controls that would be effective in preventing, or detecting and correcting, noncompliance to ensure that the Local Public Agency (LPA) Selection Review Checklist was properly supported. The lack of internal controls resulted in noncompliance. For consultant contracting (engineering and design related services) the Local Public Agency (LPA), (LaPorte County) will create and send a Request for Proposal (RFP) to the Indiana Department of Transportation (INDOT), who will review and advertise them. Consultants can then respond to those RFP's by completing and submitting a Letter of Interest (LOI). After all LOI's are received and ranked, the County reports the number of LOI's received on the LPA Selection Review Checklist. The County did not keep or maintain the Letters of Interest as reported to INDOT on the LPA Selection Review Checklist. As a result, the number on Letters of Interest documented on the checklist, provided to INDOT, could not be verified or audited. In addition, we were unable to ensure the minimum number of LOI were received to meet the procurement competition standards. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This finding will be corrected by continuing to maintain the Letters of Interest as required. Anticipated Completion Date: We will begin keeping all Letters of Interest received on, or after, November 21, 2024.

View Audit 335349

Corrective Action Plans

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