Corrective Action Plans

Finding 2024-001 Federal Agency Name: Department of Health and Human Services Program Name: Block Grants for Prevention and Treatment of Substance Abuse Federal Financial Assistance Listing Number: 93.959 Finding Summary: The Organization must establish and maintain effective internal controls over federal awards that provides assurance that the organization is managing the federal award in compliance with federal statutes, regulation, and conditions of the federal award. The Organization did not have documented review completed prior to invoice payments being made or reimbursement requests being submitted to ensure all costs incurred were allowed and in the correct period of performance under the program. Responsible Individuals: Carlie Stevens, Wellcome Manor Finance Manager; Karen Klabunde, Wellcome Manor Center Director Corrective Action Plan: On a monthly basis, the Finance Manager will provide the month’s expenditures, receipts, reimbursement requests, and recap spreadsheet to the Center Director. The Center Director will agree all items to the grant and sign the recap spreadsheet to document her review and approval. Anticipated Completion Date: December 31, 2025

Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Medical Center had a revenue calculation error of $192,326 on the HHS special report with no impact to the actual lost revenues as the quarter with the error did not result in any lost revenue being reported (i.e., lost revenue claimed was accurate on the HHS special report but key line items were misstated). Responsible Individuals: Cathy Huss, CFO Corrective Action Plan: All tracking documents that have calculations will be reviewed by the CEO if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email that they have reviewed and agree with the calculations. The calculation of lost revenues will be updated with our next reporting to HHS. Anticipated Completion Date: 6/30/2023

Corrective Action Plan: Management will ensure controls are put in place to adequately monitor all subrecipient monitoring requirements. Anticipated Completion Date: Fiscal Year 2024.

Finding 2023-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a resident revenue calculation error of $269,085 on the HHS special report with no impact to the actual lost revenues calculated (i.e. lost revenues reported were accurate on the HHS special report but key line items were misstated). Responsible Individuals: Darin Ohe, CFO Corrective Action Plan: Eventide will enhance internal control policies to ensure the HHS special report is supported by accurate revenue calculations. The resident revenue numbers will be updated to the correct numbers on the next HHS special report, if applicable. Anticipated Completion Date: 9/30/23

Finding 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 4 TIN #411419064 Federal Financial Assistance Listing: 93.498 Finding Summary: The Organization claimed lost revenues attributable to coronavirus in which the final lost revenue calculation did not tie to the HHS Report. In addition, the Organization?s special report submitted to the Department of Health and Human Services (HHS) for Period 4 TIN #411419064 did not have documented review and approval by a separate individual outside of the preparer. Responsible Individuals: Dr. Kenneth D. Varble ? Corporate Controller Corrective Action Plan: A policy will be developed outlining the controls to be followed for filing reports with Federal Agencies. This policy will reflect the procedures needed for proper internal controls to provide assurance that the Organization is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Anticipated Completion Date: December 31, 2023

Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA #93.498 Finding Summary: The Organization had a lost revenue calculation error of $141,573 on the HHS special reports causing a difference to the actual lost revenues (i.e. there were more lost revenues reported on the HHS special report). There were no questioned costs. Responsible Individuals: Darin Ohe, CFO Corrective Action Plan: All tracking documents that have calculations will be reviewed by the Vice President of Finance if the CFO compiles for accuracy and vice versa. The reviewer will sign off by email that they have reviewed and agree with the calculations. The calculation of lost revenues was updated on the period 4 report which was submitted to HHS. Anticipated Completion Date: 3/31/23

Finding 2022-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Award Number and Year: Period 4 TIN #411948604 CFDA #93.498 Finding Summary: The Organization erroneously reported $226,571 in expenses on the Period 4 Department of Health and Human Services special report. Responsible Individuals: Caroline Hood, President & CEO Paul Puerzer, Chief Financial Officer Corrective Action Plan: A policy will be developed outlining the controls to be followed for filing reports with Federal Agencies. This policy will reflect the procedures needed for proper internal controls to provide assurance that the Organization is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Anticipated Completion Date: 12/31/23

Contact Person Megan Rath 2021-004 Corrective Action Plan The Association will implement that any future report submitted to HHS for Provider Relief Funds be reviewed and approved by a second reviewer from the Association. The Association will also enhance internal controls to ensure proper supporting calculations. 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.