Corrective Action Plans

Finding 411141 (2022-001)

Material Weakness 2022

International Institute of Wisconsin, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Reporting

International Institute of Wisconsin, Inc.Single Audit Corrective Action PlanFor the Fiscal Year Ended June 30, 2022AUDIT FINDINGFinding Reference Number: 2022-001Description of Finding: Payroll and related expenses were over allocated to grants.Statement of Concurrence or Nonconcurrence:This letter...

International Institute of Wisconsin, Inc.Single Audit Corrective Action PlanFor the Fiscal Year Ended June 30, 2022AUDIT FINDINGFinding Reference Number: 2022-001Description of Finding: Payroll and related expenses were over allocated to grants.Statement of Concurrence or Nonconcurrence:This letter is in response to the condition set forth on page 34 Item #9, of the IIW 2022 Audit.Paul F. Trebian, President & CEO of IIW as of June 7, 2023, has discussed with IIW?s account and dataspecialist circumstances around the information provided on page 33 for Internal Control over majorprograms. Findings of audit indicate over allocation of FTEs against Type A (state contracts) for$250,000; and Type B (federal contracts) for $62,500.IIW agrees with the findings of the IIW 2022 Audit.Corrective Action:Currently, IIW is conducting an outside objective review of grants/contracts, since August 2022, toconfirm the audit findings for 2022 and combined with the next 2023 regular audit IIW should be able todetermine the exact amounts, any payback through adjustments made by the state for subsequentpayments after errors were made, and the nature of the over allocation of FTE?s.The reason for the need to combine with the next year 2023 audit is that the state and federal fiscal yearbeginning and ending overlap IIW?s fiscal year period.This is an important matter to investigate in an objective manner, so that we can determine a course ofaction to properly address the matter. Once the entire matter has been analyzed, IIW will be able todetermine actions to perform to provide process improvement to prevent over allocation in the future. Asa part of that process, the organization will certainly adopt the audit recommendation that it develop atime and/or activity reporting methodology to adequately document the payroll charges by grant andprogram, and that its cost allocations be reviewed and approved by the executive director.Name of Contact Person:Paul F. Trebian, Ed.D., MBA/TM, MA, BSPresident & CEOInternational Institute of Wisconsinptrebian@iiwisconsin.org414-403-9735 CellCSTProjected Completion DateIIW plans on wrapping up the investigation in a few weeks, and then will have more information tocommunicate following actions to adopt the audit recommendations and reporting methodology.QUESTIONED COSTS1. For each questioned cost, the organization should identify the amount by state financialassistance or award program and the program period.2. If the organization believes a questioned cost is an allowable cost, a statement providingreasons for the organization's position should be included.3. If the cost is questioned because the organization failed to provide the auditors withdocumentation supporting the allowability of the questioned cost, and the documentation subsequentlybecomes available, the organization should provide such documentation as part ofthe submission of the corrective action plan. The organization should describe how the records documentthe allowability of the cost.4. If the organization determines that the questioned costs are unallowable or that the chargescannot be supported, the organization should provide a statement to that effect and remit payment for theunallowable or unsupported costs with the corrective action plan.If the (Office of Policy and Management and/or Oversight Agency) has questions regarding thisPlan, please call Paul F. Trebian at 414-225-6220.Sincerely yours,Paul F. Trebian, Ed.D., MBA/TM, MA, BSPresident & CEOInternational Institute of Wisconsinptrebian@iiwisconsin.org414-403-9735 CellCST

View Audit 312029 Questioned Costs: $1

Finding 411139 (2022-002)

Significant Deficiency 2022

The Haven

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-002 Cynthia Duncan prepares SABG reporting and affirms their validity.Cynthia Duncan prepares the reports and Aimee Graves (Executive Director) affirms their validity on a monthly or quarterly basis as reports are due. This process went into effect December 1, 2022.

View Audit 312028

Finding 411137 (2022-001)

Significant Deficiency 2022

The Haven

AZ

Allowable Costs / Cost Principles Significant Deficiency

2022-001 Excessive number of Super Users in KIPU medical record system and Alli Lippard's (Billing Manager) practice of changing billing codes without supervision.The Haven reduced the number of Super Users to three Suzi Armenta (IT Manager), Kristin Lindberg (Quality Director), and Allie Lippard on...

2022-001 Excessive number of Super Users in KIPU medical record system and Alli Lippard's (Billing Manager) practice of changing billing codes without supervision.The Haven reduced the number of Super Users to three Suzi Armenta (IT Manager), Kristin Lindberg (Quality Director), and Allie Lippard on November 18, 2022.Allie Lippard sends a spreadsheet to Cynthia Duncan (Finance Director), Ryan Olson (Acting Clinical Director), and Jody Little (Outpatient Program Manager) documenting code changes required and the reason for the change. Cynthia Duncan will affirm the changes in an email response.When the charges are transferred to the Billing system Allie Lippard will run a report showing the charges in the Billing system and Cynthia Duncan will affirm via email that the charges match the modified data set. This process will be complete December 19th, 2022.

View Audit 312028

Finding 411119 (2022-002)

Significant Deficiency 2022

Baltimore City Public School System

MD

Cash Management Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the schools develop internal controls andprocedures to ensure the reports are reviewed in a timely manner to identify errorsand/or irregularities.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action planned/taken in r...

Recommendation: We recommend that the schools develop internal controls andprocedures to ensure the reports are reviewed in a timely manner to identify errorsand/or irregularities.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action planned/taken in response to finding:Baltimore City Schools had worked for many years with success, maintaining reportingand ensuring compliance, as evident in prior audit reviews. Specifically, with the FSRmonthly reporting (cash reimbursement request to grantor), prior to COVID-19,processes had been in place for completion of reporting, followed by review andapproval to include signature certification. Although reports completed, distribution ofdocuments in the process had been altered in our virtual world and unfortunately did notcontain the entire review/approval/submission process to be completely visible foroutside viewers. A more formal process will be instituted immediately with the nextreporting cycle to clearly display evidence of full reporting process for audit compliance.Reporting process will reflect report announcement, due date, identified preparer,reviewer/approver and report submission to funding agency. Full reporting process willbe documented via controlled, stamped signatory and date via electronic approvalprocess such as DocuSign and email correspondences for grantor submissions.Name(s) of the contact person(s) responsible for corrective action: Renee Calvi,Accounting ManagerPlanned completion date for corrective action plan: January 2023 (next round ofreporting)

View Audit 312027

Finding 411113 (2022-001)

Significant Deficiency 2022

Baltimore City Public School System

MD

Procurement, Suspension & Debarment

Suspension and DebarmentRecommendation: We recommend that the schools develop internal controls andprocedures to ensure that documentation of vendor?s suspension and debarment statusis maintained in accordance with the required retention policy.Explanation of disagreement with audit finding: There i...

Suspension and DebarmentRecommendation: We recommend that the schools develop internal controls andprocedures to ensure that documentation of vendor?s suspension and debarment statusis maintained in accordance with the required retention policy.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action planned/taken in response to finding:Additional language related to debarment/suspension was added to our purchase orderand to our contract boilerplate.Name(s) of the contact person(s) responsible for corrective action: Shabray Matthews,Director of Procurement.Planned completion date for corrective action plan: Already completed as of 12/9/2022.

View Audit 312027

Finding 410387 (2022-007)

Significant Deficiency 2022

Washington County Hospital

IL

Allowable Costs / Cost Principles § 200.303

Finding 2022-007Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP} Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-007Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP} Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost PrinciplesFinding Summary: The Hospital's final expenditure listing claimed payroll costs by certain departments that worked directly with COVID patients. The general ledger report that this information was generated from reports the information by department, however the payroll register does not have departmental data. Therefore, the general ledger report was not able to tie to specific department information, but it was able to tie in total.Responsible Individuals: Jennifer Venable, CFOCorrective Action Plan: Management agrees with the finding. The reporting options in the Hospital's legacy payroll system were limited. With the new system implemented in November 2021, the reports are more robust which provide the detail by department by employee. Subsequent reporting will have reports that clearly break down the detail necessary.Anticipated Completion Date: January 25, 2023

View Audit 311964

Finding 410385 (2022-006)

Material Weakness 2022

Washington County Hospital

IL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-006Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-006Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: There was no evidence of formal review and approval over tracking of expenditures that were claimed for the program. In addition, there was no evidence retained that the Hospital's special report submitted to the Department of Health and Human Services for Period 1 TIN #376020408 was reviewed or approved by an individual separate from the preparer prior to submission. The approval for individual payroll and fringe benefit expenditures was not retained in the transition to a new payroll software, and certain other expenditures did not have retained approval.Responsible Individuals: Jennifer Venable, CFOCorrective Action Plan: Management agrees with the finding. In subsequent reporting a formal approval by the CEO will be kept as part of the reporting documentation. This will include both the expenditure tracking documentation as well as the report itself. Payroll approval occurs within the payroll system. Approval logs will be retained as part of the record keeping workflow going forward .Anticipated Completion Date: January 25, 2023

View Audit 311964

Finding 410383 (2022-005)

Material Weakness 2022

Washington County Hospital

IL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2022-005Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-005Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: The Hospital claimed expenses that were incurred prior to when the Hospital began to prepare for, prevent and respond to the coronavirus. The Hospital also claimed expenses within "Other PRF Expenses" that were funded by other sources. The Hospital offset these other funding sources in later periods out of the "Other Unreimbursed Expenses". This resulted in the incorrect categorization of expenses on the special report submitted to the Department of Health and Human Services (HHS) for Period 1 which caused the report to be inaccurate.Responsible Individuals: Jennifer Venable, CFOCorrective Action Plan: Management agrees with the finding. In subsequent reporting expenses will be categorized appropriately and consideration given to align the receipt of other funding sources with the reporting of expenses within the same quarter.Anticipated Completion Date: January 25, 2023

View Audit 311964

Finding 410382 (2022-004)

Material Weakness 2022

Washington County Hospital

IL

Reporting Material Weakness

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Rura...

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Rural Health Research CentersFederal Financial Assistance Listing #93.155Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards - OtherFinding Summary: The Organization does not have an internal control system designed to provide for a complete and accurate Schedule being audited. The auditors were requested to draft the Schedule.Responsible Individuals: Jennifer Venable, CFOCorrective Action Plan: It is not cost effective to have an internal control system designed to provide for the Schedule of Expenditures of Federal Awards. We requested that our auditors, Eide Bailly LLP, prepared the Schedule. We have designated a member of management to review the drafted Schedule, and we have reviewed with and agree with the documentation proposed.Anticipated Completion Date: Ongoing

View Audit 311964

Finding 410380 (2022-004)

Material Weakness 2022

Madelia Health

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, we identified the following:- No formal documentation of review and approval of the Hospital's final expenditures listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP} Rural Distribution program (the program) was retained.- Payroll reports to support the COVID-related bonuses based on hours worked were not retained and were not able to be recreated.- Some expenses claimed under the program were incurred before the Hospital started preparing, preventing, and responding to COVID. Net costs of $36,540.- Equipment and information technology expenses claimed under other sources of funding were claimed under the program. Net actual costs of $6,080.- Utility expenses and personnel expenses were overclaimed under the program based on a review of supporting documentation. Net costs of $2,985 with projected net costs of $3,827.- No formal documentation of review and approval of the Hospital's lost revenue calculation and the Hospital's special report submitted to HHS for Period 1 TIN #410758512 was retained.- The lost revenue narrative to describe the option iii calculation did not agree with the supporting calculation performed for January and February 2021. The narrative indicated a comparison to January and February of 2019, but the calculation was done based on January and February 2020 trended revenue.- Expenses claimed under the program and included within the Hospital's special report submitted to the Department of Health and Human Services (HHS} for Period 1 TIN #410758512 were reported at gross cost and did not consider the Hospital's Medicare Cost Reimbursement percentage. Net costs of $880,880.Responsible Individuals: Bruce Craven, CFOCorrective Action Plan: Management has formally documented the review and approval process for expense data and federal agency reporting for funds received by federal agencies. This review process ensures compliance of allowable expense data federal agency reporting. Full implementation of this documented process is expected to be completed within the next month.Anticipated Completion Date: March 2023

View Audit 311963

Finding 410377 (2022-004)

None 2022

Eastern Wyoming Public Service District

WV

Reporting

June 9, 2023Eastern Wyoming Public Service District respectfully submits the following corrective action plan forthe year ended June 30, 2022.David L. Howell, CPAPO Box 458Belle, West Virginia 25015Audit Period: July 1, 2021 - June 30, 2022The findings from the June 30, 2022 schedule of findings and...

June 9, 2023Eastern Wyoming Public Service District respectfully submits the following corrective action plan forthe year ended June 30, 2022.David L. Howell, CPAPO Box 458Belle, West Virginia 25015Audit Period: July 1, 2021 - June 30, 2022The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below.The findings are numbered consistently with the number assigned in the schedule.FINANCIAL STATEMENT FINDINGS:AnticipatedFinding # Title of Finding Contact Person Completion Date2022-001 Filing of Annual Financial William Baisden, 9/30/2023and Statistical Report General ManagerCorrective action planned to be taken:The District will review and modify its policies and procedures to ensure that past due annual financial and statistical reports are completed and filed and that future reports will be filed timely as required by state code.2022-002 Water Revenue Bond William Baisden, 6/30/2024Ordinance - Rate Covenant General ManagerCorrective action planned to be taken:The District will monitor expenses and implement cost saving measures, wherepossible, and evaluate the potential need for a rate increase in order to comply with theprovisions of the bond covenants.2022-003 Working Capital Reserve William Baisden, 6/30/2024General ManagerCorrective action planned to be taken:The District will review Senate Bill No. 234 and their current rates and apply to thePublic Service Commission for a rate increase in future years, if necessary, in order to establish an adequate working capital reserve.FEDERAL AWARD FINDINGS:2022-004 Uniform Guidance Audit William Baisden, 3/31/2024Submission General ManagerCorrective action planned to be taken:The accountant for the Eastern Wyoming Public Service District will begin tracking thefinancial inflows and outflows for each construction project of the District in a mannerthat classifies each according to the appropriate Assistance Listing (AL) number andby transaction date.

View Audit 311962

Finding 410371 (2022-003)

Significant Deficiency 2022

Alamo Area Resource Center, Inc.

TX

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

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Prov...

Finding 2022-003EligibilityManagement Response: Management agrees with auditor recommendations and a plan is in place to increase the effectiveness of reviews to ensure the completeness of client certification requirements.Action Plan: 1) Identify the departments that had eligibility errors. 2) Provide comprehensive training to ensure a clear understanding of Ryan White eligibility requirements among departments.Enacted: June 2023Responsible Person: Director of Case ManagementFinalized: July 2023Action Plan: 3) The programs use a new platform, e2SanAntonio, that has a built-in feature that flags clients that are out of compliance. Will perform monthly audits of Ryan White eligibility using the new eligibility platform reporting.Enacted: April 2023Responsible Person: Director of Case ManagementFinalized: June 2023

View Audit 311961

Finding 410369 (2022-004)

Significant Deficiency 2022

Jenkins Living Center, Inc.

SD

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Princ...

Finding 2022-004Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs PrinciplesFinding Summary: An invoice was claimed that was duplicated on the COVID-19 capital items claimed under equipment.Responsible Individuals: Loren Diekman, Interim President/CEOCorrective Action Plan: We will enhance our internal control policies to ensure COVID-19 equipment purchases are eligible and properly recorded in the reports required to be submitted to the federal agency.Anticipated Completion Date: March 31, 2023

View Audit 311960

Finding 410368 (2022-003)

Material Weakness 2022

Jenkins Living Center, Inc.

SD

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Princ...

Finding 2022-003Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs PrinciplesFinding Summary: Our special report submitted to the Department of Health and Human Services for Period 1 and 2 for TIN #460242831 did not have the formal documentation of a secondary review or approval. Our lost revenue calculation was based on actual revenue billed and reported within our financial software. It was found that we had immaterial unexplained variances in the Period 1 report. In addition, we did not consider the impact of the retroactive Medicaid reimbursement adjustment applicable to quarter 3 and 4 of 2021 on the Period 2 report.Responsible Individuals: Loren Diekman, Interim President/CEOCorrective Action Plan: We will enhance the review process over special reports and ensure the lost revenue calculation when applicable will include any retro Medicaid reimbursement adjustments.Anticipated Completion Date: March 31, 2023

View Audit 311960

Finding 410367 (2022-002)

Material Weakness 2022

Jenkins Living Center, Inc.

SD

Reporting Material Weakness

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Preparation of Schedule of Expenditures of Federal AwardsMateri...

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID 19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Preparation of Schedule of Expenditures of Federal AwardsMaterial Weakness in Internal Control Over ComplianceFinding Summary: We do not have an internal control system designed to provide for the preparation of the schedule and have requested the assistance of our auditors Eide Bailly, LLP.Responsible Individuals: Loren Diekman, Interim President/CEOCorrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule and accompanying notes. We requested that our auditors, Eide Bailly LLP, prepare the schedule and the accompanying notes to schedule as a part of their audit. We have designated a member of management to review the drafted schedule and accompanying notes, and we have reviewed with and agree with the schedule.Anticipated Completion Date: Ongoing

View Audit 311960

Finding 410365 (2022-002)

Material Weakness 2022

South Dakota Achieve

SD

Allowable Costs / Cost Principles Eligibility Material Weakness

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Princi...

Finding 2022-002Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and ReportingFinding Summary: During testing, the following were identified:- Expenses were claimed under the program which were incurred prior to the Organization preparing, preventing, and responding to COVID. Actual costs of $51,160.- Payroll expenses claimed under the program were calculated for three employees with the current hourly wage rate rather than the hourly wage rate effective during the period of time COVID hours were claimed under the program. Actual costs of $3,360 with projected costs of $9,751.- One employee?s specific COVID related hours were claimed twice under the program. Actual costs of $24,096.- FICA payroll expenses were claimed twice under the program. Actual costs of $3,685.- Additional COVID payroll expenses were identified by management; however, due to a clerical error, these payroll expenses were not included in the special report submitted to HHS for Period 2 TIN #460233030 totaling $135,096.- The Organization included these expenses in the special reports submitted to the Department of Health and Human Services (HHS) for Period 2 TIN #460233030 and TIN #237072116 which caused the reports to be inaccurate. The Organization?s special reports submitted to HHS had no formal documentation of a secondary review or approval.Responsible Individuals: Stephan Wilson, Chief Financial Officer, Carol Peterson, Director of Finance, Stacy Flahaven, Accounting ManagerCorrective Action Plan: More time and attention will be given to calculating, gathering, and reporting amounts for future awards. Review and approval of federal reports will be performed by separate individuals. Both the review and approval will be formally documented by signing and dating upon completion. There are no future reporting requirements under this federal award.Anticipated Completion Date: June 30, 2023

View Audit 311959

Finding 410364 (2022-001)

Material Weakness 2022

South Dakota Achieve

SD

Reporting Material Weakness

Finding 2022-001Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Finding Summary: Auditors removed and added expenditures to the schedule of expenditure...

Finding 2022-001Federal Agency Name: Department of Health and Human ServicesProgram Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionFederal Financial Assistance Listing #93.498Finding Summary: Auditors removed and added expenditures to the schedule of expenditures of federal awards prepared by management.Responsible Individuals: Stephan Wilson, Chief Financial Officer, Carol Peterson, Director of Finance, Stacy Flahaven, Accounting ManagerCorrective Action Plan: Management will continue to track federal expenditures incurred and claimed under any federal awards received by the Organization. Management will prepare the schedule of expenditures of federal awards and provide the supporting information to support the expenditures reported.Anticipated Completion Date: June 30, 2023

View Audit 311959

Finding 410362 (2022-002)

Material Weakness 2022

Recovery Innovations, Inc.

AZ

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Material Weakness § 200.303

2022-002 Department of Health and Human ServicesFederal Financial Assistance Listing #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 2 and Period 3 TIN #711018775Activities Allowed or Unallowed and Allowable Cost...

2022-002 Department of Health and Human ServicesFederal Financial Assistance Listing #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 2 and Period 3 TIN #711018775Activities Allowed or Unallowed and Allowable Costs/Cost PrinciplesMaterial Weakness in Internal Control Over ComplianceReportingMaterial Weakness in Internal Control Over Compliance and Material NoncomplianceCondition: There was a lack of review and approval over Period 2 Provider Relief Funds lost revenue calculation and reporting. For Period 2 and Period 3, the Organization?s lostrevenue calculation did not take into consideration applicable audit adjustments for fiscal years 2021 and 2022. In addition, the Period 2 lost revenue on the Special Report to HHS did not agree to the supporting documentation.Cause: The Organization did not have an internal control process in place to ensure review and approval of the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services (HHS) for Period 2. In addition, without the inclusion of the audit adjustments, the revenue included in Period 2 and Period 3 was not materially correct.Management?s Response and Corrective Action Plan:Management placed an internal control process prior to review done for period 3 and approved the lost revenue calculation prior to submittal to the Department of Health and Human Services (HHS).Responsible Individuals: VP of Finance and Administration.Anticipated Completion Date: 1/1/2023

View Audit 311958

Finding 410339 (2022-002)

None 2022

North Central New Mexico Economic Development District

NM

GSA_MIGRATION

View Audit 311957

Finding 410338 (2022-001)

Significant Deficiency 2022

University of Delaware

DE

Reporting Allowable Costs / Cost Principles

Corrective Action PlanYear Ended June 30, 2022Finding 2022-001: HEERF ReportingCondition Found:In the review of the quarterly reporting requirement for the student aid portion, the auditors noted the University did not modify its student aid portion reporting to the quarterly requirement, but rathe...

Corrective Action PlanYear Ended June 30, 2022Finding 2022-001: HEERF ReportingCondition Found:In the review of the quarterly reporting requirement for the student aid portion, the auditors noted the University did not modify its student aid portion reporting to the quarterly requirement, but rather the University provided updates every 45 days from the date of the first student award made. The University subsequently corrected the reporting in late fiscal year 2022 and posted the quarterly reports; however they were not posted timely, as required. In addition, the auditors noted that the University?s annual report for the year ended December 31, 2021, reported certain data elements that did not agree with supporting documentation.Recommendation:Given the nature of the pandemic funding, and the evolving guidance of the compliance requirements, the auditors recommended management enhance its process level controls over reporting requirements for HEERF to ensure timely and accurate reporting in accordance with the stated reporting requirements.University of Delaware Corrective Action Plan:The University of Delaware (UD or the University) agrees that the evolving guidance created challenges in maintaining compliance. Controls over reporting requirements are expected to function effectively now that the reporting requirements are finalized.The HEERF reporting guidelines final changes required schools to change student reporting from the 15/30-day requirement to quarterly reporting. UD continued to report on a more frequent basis for student reporting. Having conferred with the Department of Education (the Department) contact, UD was required to go back and add the quarterly reports. The required forms were completed and updated on the website in August 2022.The University?s annual report for the year ended December 31, 2021, was submitted in a timely manner. However, the University is required to review and update the reported enrollment and disbursements to students based on a review by the Department. Student Financial Services (SFS) has reviewed the final disbursements as of December 31, 2021, and will only report on those disbursements claimed by students. Unclaimed funds, which have been reallocated to other students, inflated the dollar amount actually provided to students, and will no longer be included. The Department has also provided guidance to the University on the enrollment reporting. The report has been updated and was submitted to the Department of Education during the open period in March 2023.Completion Date:HEERF Student Reporting: August 2022HEERF Annual Report: March 2023Contact Person:Mary Booker, Executive Director, Student Financial Services

View Audit 311956

Finding 410072 (2022-004)

Significant Deficiency 2022

University of Delaware

DE

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.101 § 200.303 § 200.6

Corrective Action PlanYear Ended June 30, 2022Finding 2022-004: AllowabilityCondition Found:In the auditors? testing over allowability of cost, they identified one transaction in a sample of 40 non-payroll transactions for which the University paid and allocated the cost, however, the service contra...

Corrective Action PlanYear Ended June 30, 2022Finding 2022-004: AllowabilityCondition Found:In the auditors? testing over allowability of cost, they identified one transaction in a sample of 40 non-payroll transactions for which the University paid and allocated the cost, however, the service contract period had not yet started. In addition, the auditors identified a second transaction for an intergovernmental personnel agreement (in the same sample of 40 non-payroll transactions) which included an advance on future service.Recommendation:The auditors recommend the University enhance the level of precision around its internal control over compliance related to the timing of allocating and charges costs.University of Delaware Corrective Action Plan:The University agrees with this finding. The questioned costs will be removed from the grant charged. Additionally, the University will provide additional education and awareness over the billing of federal awards to ensure that expenses relate to the period being billed and services being performed.Anticipated Completion Date:July 2023Contact Person:Jeff Friedland, Associate Vice President for Research

View Audit 311956 Questioned Costs: $1

Finding 409887 (2022-003)

Significant Deficiency 2022

University of Delaware

DE

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Corrective Action PlanYear Ended June 30, 2022Finding 2022-003: Procurement: Suspended and DebarredCondition Found:In the auditor?s testing over suspension and debarment, they identified nine covered transactions in a sample of 40 procurement transactions for which the University was unable to prov...

Corrective Action PlanYear Ended June 30, 2022Finding 2022-003: Procurement: Suspended and DebarredCondition Found:In the auditor?s testing over suspension and debarment, they identified nine covered transactions in a sample of 40 procurement transactions for which the University was unable to provide supporting documentation that we verified the vendor was not suspended or debarred prior to entering into the procurement transaction with the vendor. It was determined that the related vendors were not suspended or debarred.Recommendation:The auditors recommend the University enhance its internal control over compliance with the federal regulations related to suspension and debarment to ensure covered transactions are not entered into with parties that have been suspended or debarred.University of Delaware Corrective Action Plan:The University agrees with the finding. The University will ensure suspension and debarment language is included within the contracts of all new covered transactions effective July 1, 2023 and thereafter.Additionally, the University will investigate utilizing third-party verification software to screen existing and potential vendors against the System for Award Management (SAM.gov) Exclusions list daily with expected execution by July 1, 2024.Anticipated Completion Date:Suspension and Debarment: Contract Clause ? July 1, 2023Suspension and Debarment: SAM.gov Verification ? July 1, 2024Contact Persons:Jeff Friedland, Associate Vice President for ResearchDavid Fenkel, Associate Vice President & Chief Procurement Officer

View Audit 311956

Finding 409882 (2022-002)

Significant Deficiency 2022

University of Delaware

DE

Equipment & Real Property Management § 200.303 § 200.313

Corrective Action PlanYear Ended June 30, 2022Finding 2022-002: EquipmentCondition Found:The University did not complete its physical inventory counts for 10 departments out of the 15 sampled University departments. The University has a total of 70 departments monitoring federal equipment. In addit...

Corrective Action PlanYear Ended June 30, 2022Finding 2022-002: EquipmentCondition Found:The University did not complete its physical inventory counts for 10 departments out of the 15 sampled University departments. The University has a total of 70 departments monitoring federal equipment. In addition, for one item in our sample of 40 physical inspections, we noted the property was not appropriately tagged for identification.Recommendation:The auditors recommend the University enhance its internal control over compliance around establishing property records of newly acquired federally funded equipment in accordance with applicable Federal regulations and completing the necessary physical inventories and reconciliations.University of Delaware Corrective Action Plan:The University agrees with the finding and will strengthen processes including unit and senior leadership accountability around the tagging and surveying of federally funded equipment. The University will implement management and escalation procedures with executive leadership to ensure that accountability for all completed surveys resides with the senior leader. The entire process is being evaluated and controls will be enhanced where needed and training will be expanded to include the importance of timely compliance.Anticipated Completion Date:June 2023Contact Person:Lisa Marra Kelly, Controller, Controller?s Office

View Audit 311956

Finding 409873 (2022-002)

Material Weakness 2022

Solon Community School District

IA

We have reviewed procedures and plan to make the necessary changes to improve internal control.

View Audit 311955

Finding 409869 (2022-001)

Material Weakness 2022

Belington Community Medical Services Association, Inc.

WV

Procurement, Suspension & Debarment Reporting Matching / Level of Effort / Earmarking

Corrective Action: The Organization transitioned from one CFO to a new CFO. During this period of transition, they also increased the funding being used for construction of a new clinic. The new CFO did not review the information and transactions performed by the old CFO, and this resulted in the ...

Corrective Action: The Organization transitioned from one CFO to a new CFO. During this period of transition, they also increased the funding being used for construction of a new clinic. The new CFO did not review the information and transactions performed by the old CFO, and this resulted in the initial land purchase not being properly recorded. Because the bank maintained control of the loan proceeds, the ongoing loan disbursements were not run through the normal check disbursement process by the Organization. The Organization has created a new policy to track and account for disbursements that are not run through the organizations bank accounts.

View Audit 311954

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