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Corrective Action Plans

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Finding 392121 (2021-002)
Material Weakness 2021
Pennsylvania Mountains Care Network
PA
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts ...
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts from its data supporting eligible expenditures. The adjustments needed within the PRF reports to correct the errors decreased year over year lost revenues from $21,664,944 to $11,771,346 and decreased eligible expenditures from $7,527,194 to $4,334,813, on total distributions of PRF funding of $14,972,846. In summary, the data supporting amounts for lost revenues and eligible expenses totals $16,104,159 on total distributions of PRF funding of $14,972,846 in this reporting period. Corrective Action Plan: System management agrees with the finding and has updated its lost revenue calculation. Management attempted to update lost revenue amounts with filing of its Period 4 reports; however, additional data entry errors were made. Management has worked extensively over the past two years to monitor the changing guidelines surrounding the various programs designed to respond to the COVID-19 pandemic. Management has furthered this effort by attending continuing professional education on this topic and reading available guidance to ensure that the final recordkeeping maintained by the System follows the guidance as established by HRSA.
View Audit 302290
Finding 392112 (2021-001)
Significant Deficiency 2021
Chesapeake Hospital Authority
VA
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were revi...
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were reviewed by the Vice President of Human Resources and the Finance Team, with guidance obtained from independent consultants, however, the documentation of the review was not retained. Management also notes that all expenses were deemed to be appropriately charged to the federal program. In order to ensure documentation is retained evidencing approval of costs, the Authority will require physical sign off on all invoices or electronic approval of all costs charged to the federal program.
View Audit 302275
Finding 392100 (2021-005)
Material Weakness 2021
Avita Health System
OH
Subrecipient Monitoring Material Weakness Reporting § 200.303
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost reve...
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost revenues were reported on the first period portal submission for Galion Community Hospital, another hospital of the Avita Health System. Planned Corrective Action: The portal submission could not be modified by the time we identified the reporting issue. As such, no corrective report was completed, however management will implement procedures to ensure reporting requirements are adequately reviewed for all federal funding. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024
View Audit 302244
Finding 390795 (2021-003)
Material Weakness 2021
Helping Hand House
WA
Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
View Audit 301528
Finding 387479 (2021-006)
Material Weakness 2021
Atoka County Healthcare Authority
OK
Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) 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: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022
View Audit 299648
Finding 387369 (2021-007)
Significant Deficiency 2021
Pembroke Hill School
NH
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been e...
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date : Procedure has changed a reminder will be communicated by March 30th.
View Audit 299544 Questioned Costs: $1
Finding 386977 (2021-003)
Material Weakness 2021
Healthsource Saginaw, Inc.
MI
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
View Audit 299334
Finding 380907 (2021-008)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380906 (2021-007)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380905 (2021-006)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Reporting Procurement, Suspension & Debarment § 200.303
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 380904 (2021-005)
Material Weakness 2021
Love County Health Center D/b/a Mercy Health Love County
OK
Allowable Costs / Cost Principles Material Weakness Reporting § 200.303
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
View Audit 295601
Finding 375511 (2021-002)
Significant Deficiency 2021
Church at the Park
OR
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been impl...
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been implemented in which the bank and credit card statements are reconciled to C@P’s General Ledger. These procedures were evaluated to effectiveness as part of the 2022 Single Audit. Andrew Squires, Finance Director, is responsible for the implementation of these procedures. The procedures were implemented in February of 2022 and have been followed since then. If the Department of the Treasury has questions regarding this plan, please contact Andrew at Andy.Squires@church-at-the-park.org.
View Audit 294553
Finding 375498 (2021-017)
Material Weakness 2021
Okmulgee County
OK
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303 § 200.403
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536 Questioned Costs: $1
Finding 375497 (2021-016)
Material Weakness 2021
Okmulgee County
OK
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Period of Performance § 200.303
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536
Finding 375496 (2021-015)
Material Weakness 2021
Okmulgee County
OK
Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
View Audit 294536
Finding 375495 (2021-014)
Material Weakness 2021
Okmulgee County
OK
Reporting Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.508 § 200.510
Management will work together to design and implement a system of internal controls to ensure an accurate reporting of revenues and expenditures on the SEFA, that the notes to the SEFA are prepared, and compliance with all applicable federal requirements.
Management will work together to design and implement a system of internal controls to ensure an accurate reporting of revenues and expenditures on the SEFA, that the notes to the SEFA are prepared, and compliance with all applicable federal requirements.
View Audit 294536
Finding 371311 (2021-013)
Material Weakness 2021
City of Bethel, Alaska
AK
Allowable Costs / Cost Principles § 200.303 § 200.403
Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure ...
Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure that proper reconciliations are done. Expected Completion Date Fiscal Year 2025.
View Audit 292985
Finding 371310 (2021-012)
Material Weakness 2021
City of Bethel, Alaska
AK
Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303
Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expecte...
Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expected Completion Date Fiscal Year 2025.
View Audit 292985
Finding 371305 (2021-007)
Significant Deficiency 2021
City of Bethel, Alaska
AK
Reporting § 200.303
Finding 2021‐007 Late Reporting – Significant Deficiency in Internal Control over Compliance Corrective Action Plan Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Expected Completion Date Fiscal Year 2025.
Finding 2021‐007 Late Reporting – Significant Deficiency in Internal Control over Compliance Corrective Action Plan Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Expected Completion Date Fiscal Year 2025.
View Audit 292985
Finding 371304 (2021-006)
Material Weakness 2021
City of Bethel, Alaska
AK
Allowable Costs / Cost Principles § 200.303 § 200.430
Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rate...
Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rates agree to the most current pay rate as is specified in the employee’s current personnel action form. Expected Completion Date Fiscal Year 2025.
View Audit 292985
Finding 370512 (2021-004)
Material Weakness 2021
Elmore County Commission
AL
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303
The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these...
The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these type items to ensure clarity of reimbursement s and/or costs moving forward on state and federally funded projects.
View Audit 292133 Questioned Costs: $1
Finding 370141 (2021-005)
Material Weakness 2021
Town of Livermore Falls
ME
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Poli...
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.
View Audit 291678
Finding 370139 (2021-003)
Material Weakness 2021
Town of Livermore Falls
ME
Allowable Costs / Cost Principles § 200.303
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the ...
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.
View Audit 291678
Finding 370053 (2021-008)
Material Weakness 2021
Delaware County
OK
Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking § 200.303
The Board of County Commissioners will work with all Count Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all Count Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
View Audit 291562
Finding 369744 (2021-008)
Material Weakness 2021
New Vision Foundation
MN
Matching / Level of Effort / Earmarking Cash Management Material Weakness § 200.303
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the...
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the clicker reports, and retain specific documentation as to the variances. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Documentation of meal count sheets and clicker reports were accepted and approved by the sponsoring organization. Additional documentation was not requested nor were any changes to management’s practices. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A
View Audit 291230
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