Corrective Action Plans

Finding 514410 (2021-004)

Material Weakness 2021

Town of Newport

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

FINDING 2021-004 Finding Subject: Water and Waste Disposal System for Rural Communities - Reporting Summary of Finding: There was no documented oversight, review or approval process to ensure the required RD 442-2 (Statement of Budget, Income and Equity) and RD 442-3 (Balance Sheet) reports were com...

FINDING 2021-004 Finding Subject: Water and Waste Disposal System for Rural Communities - Reporting Summary of Finding: There was no documented oversight, review or approval process to ensure the required RD 442-2 (Statement of Budget, Income and Equity) and RD 442-3 (Balance Sheet) reports were completed and submitted timely and accurately to the Department of Agriculture (USDA). Due to the lack of internal controls, the Town did not submit required RD 442-2 and 442-3 reports to the USDA during the audit period. Contact Person Responsible for Corrective Action: Rachel West, Clerk-Treasurer Contact Phone Number and Email Address: 765.492.8110 / newport.indiana@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Required forms will be prepared and submitted for approval prior to submission. Anticipated Completion Date: March 1, 2025

View Audit 332703

Finding 514409 (2021-003)

Material Weakness 2021

Town of Newport

IN

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

FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Internal Controls Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the Town in order to ensure compliance with requirements related to th...

FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Internal Controls Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the Town in order to ensure compliance with requirements related to the grant agreement and the following compliance requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles & Matching. Contact Person Responsible for Corrective Action: Rachel West, Clerk-Treasurer Contact Phone Number and Email Address: 765.492.8110 / newport.indiana@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Implement a system of checks and balances to ensure disbursements made are allowable and in accordance with contract provisions relating to grants. Include federal expenditures in monthly board minutes. Anticipated Completion Date: November 12, 2024

View Audit 332703

Finding 513237 (2021-003)

Material Weakness 2021

Republic of Palau

PW

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

2021-003 Program concurs and working with MOF management to correct the finding On-going Glendalynn Ngirmeriil Executive Director Palau WIOA Office Contact: 680-488-2513 Email: gngirmeriil.wioa@gmail.com

View Audit 331185 Questioned Costs: $1

Finding 512304 (2021-002)

Material Weakness 2021

American Indian Community Center Association

WA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.303

FINDING 2023-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physica...

FINDING 2023-002 – Equipment & Real Property Management; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Views of responsible officials and planned corrective actions: Management agrees with the assessment and understands the importance of regular physical inventories. The Organization has designed an internal control process that will be implemented by August 30th, 2024. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 330075 Questioned Costs: $1

Finding 504930 (2021-002)

Material Weakness 2021

City of Long Beach

CA

Reporting Matching / Level of Effort / Earmarking Cash Management § 200.303 § 200.502 § 200.510

Program: Transportation Infrastructure Finance & Innovation Action (TIFIA) Program (ALN 20.223) Finding: 2021-002 Contact Person: Wei Chi Director of Finance City of Long Beach Harbor Department Phone: (562) 283-7594 Email: wei.chi@polb.com Corrective Action Plan: Going forward, the Harbor Depart...

Program: Transportation Infrastructure Finance & Innovation Action (TIFIA) Program (ALN 20.223) Finding: 2021-002 Contact Person: Wei Chi Director of Finance City of Long Beach Harbor Department Phone: (562) 283-7594 Email: wei.chi@polb.com Corrective Action Plan: Going forward, the Harbor Department will ensure that federal loans are reported on the SEFA. The expected completion date for implementation of these planned actions is no later than June 30, 2025.

View Audit 327686

Finding 504929 (2021-001)

Significant Deficiency 2021

City of Long Beach

CA

Reporting § 200.303 § 200.328

Program: Airport Improvement Program Finding: 2021-001 Contact Person: Mony Chhey Financial Services Officer Long Beach Airport Phone: (562)570-2664 Email: Mony.Chhey@longbeach.gov Corrective Action Plan: The Airport Department will provide more training to staff that are involved with the prepa...

Program: Airport Improvement Program Finding: 2021-001 Contact Person: Mony Chhey Financial Services Officer Long Beach Airport Phone: (562)570-2664 Email: Mony.Chhey@longbeach.gov Corrective Action Plan: The Airport Department will provide more training to staff that are involved with the preparation, review and approval of the reports to reduce the risk of misinterpreting reporting requirements. The Airport Department will also strengthen internal controls by requiring at least two levels of review for Federal Financial Report SF 425, prior to submission. These improvements to the process will ensure that reports are complete and accurate. The expected completion date for implementation of these planned actions is no later than July 31, 2022.

View Audit 327686

Finding 502335 (2021-007)

Material Weakness 2021

Alfalfa County

OK

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.84

In each of our districts we will practice oversight and due diligence over the documentation of Disaster Grant expenditures. We will review documents to ensure labor rates and equipment rates were those approved FEMA. We will acknowledge our review by signing the documents.

View Audit 324377 Questioned Costs: $1

Finding 502334 (2021-006)

Material Weakness 2021

Alfalfa County

OK

Special Tests & Provisions Allowable Costs / Cost Principles Period of Performance § 200.303

We will research the compliancerequirements for each Major Federal Grant the County receives. Withthe compliance requirements in mind, we will establish policies and procedures to satisfy those requirements and practice oversight over federal grant activity.

View Audit 324377

Finding 502216 (2021-004)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Significant Deficiency § 200.303

Finding 2021-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1624185 (9/16/2016...

Finding 2021-004: Payroll Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1624185 (9/16/2016 – 8/31/2022), 1726113 (8/1/2017 – 9/30/2023) Condition: Payroll approvals for individuals are not always made by individuals who are the employee’s supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Of the 31 individual payroll payments tested to 7 separate individuals, totaling $63,848, we identified 16 total payments to 4 separate individuals, totaling $14,907 charged to federal grants, where the timesheet was approved by the CFO, who we do not consider to be knowledgeable of the employee’s activities during a given pay period. One of these four individuals was a full-time employee and the other three were part-time employees. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correctly reflect the employee’s assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 324370

Finding 502205 (2021-002)

Material Weakness 2021

American Association of Physics Teachers, Inc.

MD

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

Finding 2021-002: Segregation of Duties Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431...

Finding 2021-002: Segregation of Duties Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1524963 (11/1/2015 – 9/30/2021), 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022), 1720869 (5/15/2017 – 4/30/2022), 1726113 (8/1/2017 – 9/30/2023), 1821462 (7/1/2018 – 6/30/2024), 1812860 (9/1/2018 – 8/31/2020), 1940925 (1/15/2020 – 12/31/2023), 1907950 (7/1/2019 – 6/30/2024), 2015205 (4/1/2020 – 3/31/2022), 2021059 (10/1/2020 – 9/30/2024) Federal Program: Research and Development Cluster (Mathematical and Physical Sciences) Assistance Listing Number and Title: 47.049 Mathematical and Physical Sciences Name of Federal Agency, Pass Through Entity, Award Number and Year: National Science Foundation: 1821372 (10/1/2018 – 9/30/2024 pass through entity American Physical Society), 1834530 (9/1/2018 – 8/31/2025 pass through entity American Physical Society), 1938815 (8/1/2020 – 7/31/2024) Federal Program: Research and Development Cluster (Science) Assistance Listing Number and Title: 43.001 Science Name of Federal Agency, Pass Through Entity: National Aeronautics and Space Administration: NNX16AR36A (8/24/2016 – 8/23/2021 pass through entity Temple University of the Commonwealth System of Higher Education), 80NSSC21K1560 (6/28/2021 – 6/27/2022 pass through entity Temple University of the Commonwealth System of Higher Education) Condition: The Chief Financial Officer is responsible for posting entries into the accounting system without a second level review, and obtaining all bank statements unopened while also having the ability to add or modify payees and unilaterally initiate and authorize electronic fund transfers such as automated clearing house payments. The CFO is also responsible for opening the mail which may contain payments by check, and can manually reduce receivable balances. Views of Responsible Officials and Planned Corrective Actions: AAPT has instituted the segregation of duties of submitting and approval of electronic payments. The senior accountant has been authorized to submit the ACH/Wire transfer requests. The CFO has the authorization of approval of submitted electronic payments. The change was activated around March 15, 2024 The staff will be trained on generating journal entries previous prepared by the CFO and supervised and approve by the CFO – completed date May 15, 2024 The administrative assistant of the CEO will come to AAPT twice weekly to process incoming mail and create an initial recordation log of checks or cash received. The administrative assistant will not have access in any system to enter/modify/delete any information related to checks that are received. Anticipated Completion Date: January 2025 Responsible Official: Michael Brosnan, CFO

View Audit 324370

Finding 498573 (2021-003)

Material Weakness 2021

Wishek Hospital Clinic Association D/b/a South Central Health

ND

Allowable Costs / Cost Principles § 200.303

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider R...

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider Relief Funds, a second reviewer will document approval of such reports. Completion Date The corrective action plan steps were implemented in part in 2022 with continued improvements planned to be in place by October 1, 2024.

View Audit 321318

Finding 496357 (2021-101)

Material Weakness 2021

Inter-Tribal Council of Nevada, Inc.

NV

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

We agree with the findings 2021-001, 2021-003, and 2021-004, and acknowledge that this issue has been previously identified in past audits. The repeat occurrence was primarily due to understaffing and turnover within the finance, WIC, CCDF, Head Start, FVPP, and WIC departments, followed by addition...

We agree with the findings 2021-001, 2021-003, and 2021-004, and acknowledge that this issue has been previously identified in past audits. The repeat occurrence was primarily due to understaffing and turnover within the finance, WIC, CCDF, Head Start, FVPP, and WIC departments, followed by additional staffing challenges during and post COVID 19 pandemic of 2020. In addition to the Corrective Action Planned related to Finding 2020-101, with respect to the WIC, CCDF, Head Start and FVPP programs, the Executive Director has required additional training for the Program Directors on internal controls, and relevant fiscal and administrative grant training following review of the prior repeat audit findings. We have been implementing collaboration between program directors and fiscal staff to improve overall compliance for grant funds, including budgeting, reporting, policies and procedures and processes. Anticipated Completion Date: On-going – Final Grants Management Document expected to be presented and adopted by the ITCN executive board by September 30, 2025. The Final FY 2021 Financial Statements, including the Corrective Action Planned will be presented to the executive board and program directors for overview. The Executive Director will be responsible for on-going communication and engagement to improve internal controls, and regularly scheduling meetings for status updates on the Corrective Action Planned and review quarterly reports. Beginning January 2022, we have developed and drafted a grants management handbook as a resource for program and fiscal staff. As we continue to make improvements and amendments to internal processes and policies and procedures, the grants management will be updated, with a final copy presented to the Executive Board for adoption and approval.

View Audit 319246

Finding 481174 (2021-003)

Significant Deficiency 2021

Regional Office of Education #47

IL

Subrecipient Monitoring § 200.303 § 200.332

FINDING 2021-003 – Subrecipients Monitoring (Repeated from Prior Year Findings 20-004, 19-005, 18-004, and 17-003) CONDITION: The ROE does not have effective internal controls over subrecipient monitoring. Furthermore, ROE #47 was not properly monitoring subrecipients in accordance with the Unif...

FINDING 2021-003 – Subrecipients Monitoring (Repeated from Prior Year Findings 20-004, 19-005, 18-004, and 17-003) CONDITION: The ROE does not have effective internal controls over subrecipient monitoring. Furthermore, ROE #47 was not properly monitoring subrecipients in accordance with the Uniform Guidance standards. During audit testing procedures it was determined that ROE #47: Number of Subrecipients a. Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. 2 of 2 b. Did not conduct subrecipient monitoring procedures 2 of 2 c. Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit Requirements criteria for a single audit. 2 of 2 PLAN: Regional Office of Education will implement the following internal controls over Federal awards to ensure subrecipients are properly monitored as required by 2 CFR 200.332. This includes: a. Evaluating the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward; b. Conducting subrecipient monitoring procedures; and c. Determining whether the subrecipient met the requirement criteria of 2 CFR 200 Subpart F Audit requirements for a single audit. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2021 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

View Audit 317271

Finding 480926 (2021-008)

Material Weakness 2021

Puerto Rico Electric Power Authority

PR

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining con...

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining constant communication with stakeholders to prevent material noncompliance. Additionally, PREPA will provide training to staff on the new SOPs and establish a monitoring mechanism to continuously assess and improve the effectiveness of these controls. The corrective action plan, supervised by Mr. Ezequiel Nieves from the PREPA Disaster Funding Management Office, is expected to be completed by July 2025. Management is committed to addressing deficiencies, ensuring that processes and controls are robust and effective, and that Federal awards are managed transparently and in full compliance with all regulatory requirements. Effective June 1, 2021, the Authority transitioned the management and operation of its transmission and distribution network as well as certain back- office functions, including billing, collections and accounting, to a third party. The third-party operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. Management will work to address these findings with the assistance of the third-party operators, where applicable. Also, effective July 1, 2023, the Authority transitioned the management and operation of its generation assets as well as certain back- office functions to a third party. The thirdparty operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. In addition, the Authority will also be implementing and monitoring corrective actions taken by the new generation segment operator. Contact Name Responsible for Corrective Action Plan - Ezequiel Nieves Estimated Completion Date - July 2025

View Audit 317030

Finding 480856 (2021-004)

Significant Deficiency 2021

American Association of Physics Teachers, Inc.

MD

Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Vie...

Finding 2021-004: Payroll Federal Programs: Research and Development Cluster: 47.0746 Condition: Payroll approvals for individuals are not always made by individuals who are the employee's supervisors or are otherwise knowledgeable about their level of effort during the payroll periods paid for. Views of Responsible Officials and Planned Corrective Actions: AAPT has made changes to correclty reflect the employee's assigned supervisor based on the position and job duties of the employees. Anticipated Completion Date: 04/01/2024 Responsible Official: Michael Brosnan, CFO

View Audit 316985

Finding 479433 (2021-002)

Material Weakness 2021

Unity Medical Center INC

TN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.507

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal awar...

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Section 200.507 of the Uniform Guidance states that the program-specific audit shall be completed, and reporting required submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit, unless a longer period is specified in a program-specific audit guide. During 2023, we have strengthened internal controls related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. Going forward, we will complete our audits and submit the required reports by the deadlines. We have taken appropriate steps to identify all other assistance received by quarter during the period of availability on the PRF report going forward.

View Audit 315964

Finding 406039 (2021-002)

Significant Deficiency 2021

Hospital Damas INC

PR

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

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022

View Audit 311582

Finding 404941 (2021-008)

None 2021

Clark County Fiscal Court

KY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure are compliant.

View Audit 311338

Finding 404940 (2021-007)

Material Weakness 2021

Clark County Fiscal Court

KY

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

County Judge/Executive’s Response: The Fiscal Court has contracted with Compass to ensure that expenses for Federal Reimbursement are eligible for reimbursement.

View Audit 311338 Questioned Costs: $1

Finding 404821 (2021-007)

Material Weakness 2021

Shattuck Hospital Authority D/b/a Newman Memorial Hospital, Inc.

OK

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federa...

Compliance Finding 2021‐007 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal, states, regulations and conditions of the federal award. Corrective Action Plan: We will modify internal control policies to ensure there is an understanding of reporting requirements to ensure that reports are accurate and amounts are not inadvertently claimed that are considered unallowable. Responsible Individual: Doran Hammett, Chief Financial Officer Anticipated Completion Date: June 2024

View Audit 311207

Finding 402820 (2021-001)

Significant Deficiency 2021

Brownfield Regional Medical Center

NM

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.303 § 200.403 § 200.430

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. ...

Recommendation: The Auditor recommends that the Entity implement controls for documenting and retaining information on expenditures charged to federal awards to follow the requirements over 2 CFR Section 200.430(g)(i) and in addition the Entity is properly paying employees at the approved pay rate. Action Taken: 1. Policy Revision and Development: o Develop or revise existing policies to clearly define the processes for documenting and retaining expenditure information related to federal awards. These policies should explicitly follow the requirements over 2 CFR Section 200.430(g)(i), ensuring that all expenditures are properly documented and justified as per federal award conditions. Specifically, approval of differential rates will be added to those policies. o Ensure that the policy includes guidelines for regularly reviewing employee pay rates against approved rates for compliance with federal award conditions. 2. Training and Awareness Programs: o Implement comprehensive training programs for all staff involved in charging costs to federal awards. This training should cover the importance of compliance with federal regulations, specifically focusing on the documentation and retention of expenditure information and adherence to approved pay rates. o Schedule regular refresher training sessions to ensure ongoing compliance and awareness. 3. Enhanced Monitoring and Audit Trails: o Introduce monitoring mechanisms to regularly review expenditures charged to federal awards for compliance with documented policies and federal requirements. o Develop an audit trail system that allows for the easy retrieval of documentation supporting expenditures and payroll compliance. This system should enable auditors to trace the documentation back to the federal award and the approved budget items. 4. Internal Control Improvements: o Review and strengthen internal controls related to the processing of expenditures and payroll to ensure that all transactions are authorized, recorded accurately, and in compliance with federal award requirements. o Implement segregation of duties where possible, to reduce the risk of errors or fraud in the charging of costs to federal awards. 5. Regular Compliance Reviews and Updates: o Conduct periodic internal reviews to assess compliance with federal award requirements and the effectiveness of the implemented corrective actions. o Ensure that any changes in federal regulations or award-specific requirements are promptly incorporated into the hospital's policies and training programs. 6. Documentation and Communication: o Maintain comprehensive records of all actions taken to address the audit findings, including policy revisions, training sessions, and internal review outcomes. Specifically, records for those these expenditures will remain onsite and not sent to long-term storage if the employee or vendor no longer has a relationship with the facilities. o Communicate regularly with federal awarding agencies to update them on the corrective actions taken and to seek guidance on compliance matters as needed. Implementation Timeline and Responsibility Assignment: • Management positions including the CEO, CFO and CNO for the 2021 fiscal year are no longer employed by Terry Memorial Hospital District. Administration employed in 2023 acknowledges these deficiencies and accepts responsibility for developing, applying and maintaining this corrective action plan going forward. • Assign specific responsibilities to designated staff members or departments for each component of the corrective action plan. • Set clear deadlines for the completion of each action item, with an initial goal to address all significant deficiencies within one to three months from the date of the audit report. Monitoring and Reporting: • Establish a mechanism for ongoing monitoring of the effectiveness of the corrective action plan, with periodic reports to senior management and the board of directors. Feedback Loop: • Create a feedback loop with employees and management to continuously improve internal controls and compliance processes based on practical experiences and challenges encountered during implementation. Responsible Person: Whitney Wilson, CFO

View Audit 310010 Questioned Costs: $1

Finding 402384 (2021-016)

Material Weakness 2021

State of California

CA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference...

Of the 20 claimants the auditor determined to be ineligible for Lost Wages Assistance (LWA) benefits, 17 were Pandemic Unemployment Assistance (PUA) claimants disqualified due to identity issues discovered through the EDD’s new fraud enhancements outlined in the response to the finding for Reference Number 2021-003. The other three claimants were receiving regular Unemployment Insurance (UI) benefits (one claimant) and Pandemic Emergency Unemployment Compensation (PEUC) benefits (two claimants). Those three claimants were paid pending the adjudication of potential eligibility issues, which were later found to be disqualifying. EDD has corrected both issues that resulted in the LWA payments being made to ineligible claimants. Regarding the issue of PUA claimants paid prior to the discovery of the potential identity issues, as outlined in the response to the finding for Reference Number 2021-003, during the years 2020 and 2021, the EDD implemented multiple new fraud prevention measures. Regarding the issue of the regular UI and PEUC claimants being paid prior to the adjudication of the potential eligibility issues, the EDD resumed adjudicating all potential eligibility issues as of January 2021 and will complete the remaining retroactive workload by April 30, 2023. Estimated Implementation Date: September 2020 (Fraud Enhancements) and January 2021 (Resumption of Adjudications) Contact: Diane Underwood, Division Chief Unemployment Insurance Branch California Employment Development Department

View Audit 309913 Questioned Costs: $1

Finding 402380 (2021-015)

Significant Deficiency 2021

State of California

CA

Questioned Costs Reporting Special Tests & Provisions § 200.303

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assista...

Health Care Services agrees with the recommendation. Effective September 1, 2021, System Development Notice (SDN) 20039 made updates to the Claims Processing Accounts Receivable System, requiring the Fiscal Intermediary (FI) to record the FFP rate including the Budget Program (i.e., Medicaid Assistance Program vs. Children’s Health Insurance Program) for each overpayment account receivable set up after the effective date. The FFP rate and Budget Program information for each overpayment is provided on the Action Notices to the FI. The SDN also made updates to the California Omnibus Budget Reconciliation Act of 1985 (COBRA) system to enable the system to receive the FFP rate and Budget Program information for each overpayment set up by the FI and updated COBRA reports, thereby allowing Health Care Services to report the correct FFP rate for overpayments on the CMS-64 and CMS-21. Estimated Implementation Date: September 30, 2021 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services

View Audit 309913 Questioned Costs: $1

Finding 402379 (2021-014)

Material Weakness 2021

State of California

CA

Subrecipient Monitoring § 200.303 § 200.332 § 200.501 § 200.513 § 200.521

Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrec...

Public Health agrees with the recommendation. We will establish formal procedures for conducting risk assessments of our subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures and establish a process for obtaining single audit reports from out subrecipients. Finally, we will develop a monitoring mechanism to track subrecipients' compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health

View Audit 309913

Finding 402371 (2021-011)

Material Weakness 2021

State of California

CA

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

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guideli...

The Office of AIDS (OA) agrees with the finding and recommendation. OA developed and implemented additional, internal quality assurance (QA) processes in April of 2022 to ensure that secondary reviews of AIDS Drug Assistance Program (ADAP) applications are consistently enforcing the existing guidelines, including acceptable supporting documentation and accurate eligibility requirements. During this audit period, and through December 2021, ADAP had issued multiple policy memos to respond to the COVID-19 pandemic, which enabled staff and enrollment workers to defer documentation collection, when necessary, to remain flexible and ensure clients impacted by the pandemic, and associated site closures, did not lose eligibility and access to life saving medications and comprehensive healthcare. These flexibilities in our guidelines were implemented based on guidance received from our federal funder, Health Resources and Services Administration (HRSA), which encouraged ADAPs to reassess their organization's eligibility and recertification policies and procedures, and remove any barriers that may impede social distancing, or other public health strategies, necessary to minimize COVID-19 transmission. This documentation deferral was terminated on December 31, 2021, and since January 1, 2022, full documentation and eligibility requirements have been enforced. This, combined with ongoing QA efforts, will help to mitigate future findings in ADAP applications dated January 1, 2022 onward. Estimated Implementation Date: Already implemented as of April 2022 Contact: Sharisse Kemp, Branch Chief AIDS Drug Assistance Program Branch California Department of Public Health

View Audit 309913

Corrective Action Plans

Filters