Corrective Action Plans

Finding 394530 (2021-107)

Material Weakness 2021

FL

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022...

Lack of Documentation for Expenses Submitted for Reimbursement Condition: The Organization submitted costs for reimbursement of medical supplies which could not be supported with related invoices. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417 Questioned Costs: $1

Finding 394529 (2021-106)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring HUD Housing Programs Significant Deficiency § 200.303

Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample sele...

Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Corrective Action Planned: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394528 (2021-105)

Material Weakness 2021

Pancare of Florida, INC

FL

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...

Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394527 (2021-102)

Significant Deficiency 2021

Pancare of Florida, INC

FL

Cash Management § 200.303

Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hire...

Lack of Cash Management Documentation Condition: The Organization made drawdowns after month-end based on budgeted period expenditures. Insufficient documentation was kept to clearly document that the amount requested was reviewed for accuracy. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organizations policy and procedures related to support documentation retention has been evaluated and updated. Supporting documentation for all drawdown requests are retained by grant. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented

View Audit 304417

Finding 394526 (2021-101)

Material Weakness 2021

Pancare of Florida, INC

FL

Subrecipient Monitoring Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identi...

Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: July 1, 2024

View Audit 304417

Finding 394021 (2021-004)

Material Weakness 2021

Abilities Network, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.407

Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...

Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 4/1/2024

View Audit 304152 Questioned Costs: $1

Finding 394020 (2021-003)

Significant Deficiency 2021

Abilities Network, Inc.

MD

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.328 § 200.329

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to sup...

U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to support amounts reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will maintain evidence of timely submission of reports, review of reports and documentation to support amounts reported. Additionally, management will implement a formal documentation retention policy. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 3/1/2024

View Audit 304152

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.

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.

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.

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.

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.

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

Corrective Action Plans

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