Corrective Action Plans

Finding 32389 (2022-001)

Material Weakness 2022

Christian Housing of St. Joseph, INC Chilton Place Apts.

MO

HUD Housing Programs Procurement, Suspension & Debarment Reporting

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Audit: Christian Housing of St. Joseph, Inc. HUD Project Number: 084-11148 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Tamara Wallace Position: Executive Director ? Management Agent Telephone Number: 816-233-4250 Findings-Financial Statement Audit None Findings-Federal Award Program Audit Federal Agency: Department of Housing and Urban Development Major Program: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects Section 207/223f Assistance Listing Number: 14.155 Finding 2022-001 Comments on Findings and Each Recommendation: The Organization agrees with the auditors? finding. Action(s) Taken or Planned on the Finding: Management will ensure that the accounts reconcile to source documents, including report from the software used to process tenant rental activities. Management expects to establish the process by September 30, 2022.

View Audit 27889

Finding 32385 (2022-001)

Significant Deficiency 2022

Elder Care Services, Inc.

FL

Matching / Level of Effort / Earmarking Reporting § 200.303

Beginning October 2023, prior to submission of required reports, clinical directors, Zoila Huston (Leon County) and Mariposa Wilson (Gadsden & Wakulla counties) will ensure the reports are reviewed and approval is documented through signature of the CEO, Jocelyne Fliger. Additionally, documentation ...

Beginning October 2023, prior to submission of required reports, clinical directors, Zoila Huston (Leon County) and Mariposa Wilson (Gadsden & Wakulla counties) will ensure the reports are reviewed and approval is documented through signature of the CEO, Jocelyne Fliger. Additionally, documentation of submission of those reports will be obtained through either appropriate signature, electronic confirmation or equivalent.

View Audit 28092

Finding 32382 (2022-003)

Material Weakness 2022

Intercare Community Health Network

MI

Eligibility

In Response to Federal Award Finding, Finding 2022-003 ? Material Weakness and Material Noncompliance ? Special Tests ? Sliding Fee. Health centers must obtain sliding fee applications so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient...

In Response to Federal Award Finding, Finding 2022-003 ? Material Weakness and Material Noncompliance ? Special Tests ? Sliding Fee. Health centers must obtain sliding fee applications so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. We tested 60 sliding fee encounters and noted that 1 of 60 sliding fee encounters tested received the wrong slide. We noted 6 of 60 sliding fee applications were missing an approving sign off. We noted 2 of 60 sliding fee applications were missing and not on file. We noted 1 out of 60 sliding fee applications did not properly document an extension in the slide eligibility period. We noted 1 out of 60 sliding fee encounters was not properly charged a lab visit fee in accordance with the policy. Lastly, we noted 1 out of 60 sliding fee encounters had a wrong correcting adjustment applied to the patient account. Responsible Person: Stephanie Smith, CPA, Chief Financial Officer Corrective Action Planned: Management will ensure sliding fee applications are completed and properly approved and that discounts for eligible patients are properly calculated, documented in files, processed and extended correctly when applicable, for each sliding fee patient. Management has carefully revised training materials for staff as well as new staff, and will work to ensure controls are followed to verify sliding fee discounts applied are correct based on the patient application. To help ensure compliance, the organization has already begun conducing sampling throughout the year to verify sliding fee applications are obtained, completed correctly, and applied accurately to accounts. Anticipated Completion Timeframe: To be completed by 3/31/23.

View Audit 27204

Finding 32381 (2022-001)

Material Weakness 2022

Town of Swansea

MA

Equipment & Real Property Management Allowable Costs / Cost Principles

DEPARTMENT OF EDUCATION 2022-001 Elementary and Secondary School Emergency Relief (ESSER) Funds ? Assistance Listing No.?s 84.425D and 84.425U Recommendation: We recommend the Town apply its procedures for the management of equipment and real property purchased with federal awards to all expenditure...

DEPARTMENT OF EDUCATION 2022-001 Elementary and Secondary School Emergency Relief (ESSER) Funds ? Assistance Listing No.?s 84.425D and 84.425U Recommendation: We recommend the Town apply its procedures for the management of equipment and real property purchased with federal awards to all expenditures of this type; including HVAC and other building improvements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All purchases that need to be identified as equipment and asset tagged will have the proper labeling. Name(s) of the contact person(s) responsible for corrective action: Randi Arruda Planned completion date for corrective action plan: 3/28/2023

View Audit 28206

Finding 32380 (2022-002)

Material Weakness 2022

Town of Swansea

MA

Questioned Costs Allowable Costs / Cost Principles Period of Performance

DEPARTMENT OF TREASURY 2022-002 COVID-19 Coronavirus Relief Funds ? Assistance Listing No. 21.019 Recommendation: We recommend the Town strengthen its internal controls over compliance to ensure allowable costs charged to federal programs are incurred during approved performance periods. Explanation...

DEPARTMENT OF TREASURY 2022-002 COVID-19 Coronavirus Relief Funds ? Assistance Listing No. 21.019 Recommendation: We recommend the Town strengthen its internal controls over compliance to ensure allowable costs charged to federal programs are incurred during approved performance periods. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Understood. Name(s) of the contact person(s) responsible for corrective action: Randi Arruda Planned completion date for corrective action plan: Deadlines will be adhered to.

View Audit 28206 Questioned Costs: $1

Finding 32372 (2022-001)

Material Weakness 2022

School District of Haveford Township

PA

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

Management?s Response: Management will implement safeguards to ensure responsible business office employees are held accountable for following procedures to ensure timely and complete monthly and annual financial reporting.

View Audit 28232

Finding 32371 (2022-002)

Material Weakness 2022

Inova Health System

VA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Recommendation: Inova Juniper Program?s (IJP) existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are bei...

Recommendation: Inova Juniper Program?s (IJP) existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification for all clients. View of Responsible Officials: Management concurs with the finding and has implemented, during 2021 and 2022, procedures to ensure the appropriate oversight is performed regarding eligibility. inova.org Inova Health Care Services Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Mara Carter, Senior Director Community Health, Inova Juniper Program, 703-321-2687 Planned Completion Date for Corrective Action Planned: Corrective action plan has been implemented.

View Audit 27876 Questioned Costs: $1

Finding 32370 (2022-003)

Significant Deficiency 2022

Inova Health System

VA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Recommendation: The System?s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of Responsible Officials: There is no disagreement with the audit finding. Corrective Action Planned: Management will design and ensure written policies and pr...

Recommendation: The System?s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of Responsible Officials: There is no disagreement with the audit finding. Corrective Action Planned: Management will design and ensure written policies and procedures will be created outlining processes and control activities to ensure reporting to federal awarding agencies and pass-through entities are complete and accurate. During the current fiscal year, Inova began implementing enhancements to Oracle?s Grants Accounting module. Once completed, this will assist management to automate certain processes and procedures that were not available after the initial implementation. The enhanced reporting capabilities will include automated reporting that will identify grants that expended federal awards. Grants Accounting will schedule quarterly meetings with Finance and GMO leadership present. The purpose of these meetings will be to review federal funding received that will ultimately be used in the preparation of financial reports submitted to the appropriate governing agencies. The Director of Grants Accounting will guide the meetings and obtain approvals from department leaders confirming amounts to be reported for federal grant awards. In preparation of the meetings, the Director of Grants Accounting will prepare an agenda to guide discussions of grant terms and conditions and applicable FAQs, more explicitly for awards received outside of Inova?s normal course of business (i.e., COVID-19). These meetings will also provide an opportunity for Finance, GMO, and Grants Accounting leaders to review the unique characteristics of the federal grant award programs on at least a quarterly basis. Meeting minutes will be maintained to document discussions and actions to be taken. The minutes will also serve as support for accounting memos related to special awards received that document Inova?s understanding of the award and related reporting requirements. All accounting memos will be prepared by the Director of Grants Accounting and reviewed by the Senior Director of Financial Reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Planned completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2023.

View Audit 27876

Finding 32369 (2022-001)

Significant Deficiency 2022

Inova Health System

VA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are accurate. View of Responsible Officials: Management concurs with the finding and will implement procedures ...

Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are accurate. View of Responsible Officials: Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission. Name(s) of the Contact Person(s) Responsible for Corrective Action: Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122. Christopher Trump, Senior Director of Financial Reporting, 571-373-2868. Michael H. Lowen, Director, Grant Accounting, 571-472-8108. Planned Completion Date for Corrective Action Planned: Ongoing with a completion date of December 31, 2023.

View Audit 27876

Finding 32367 (2022-001)

Material Weakness 2022

Vermont State Colleges

VT

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.007, 84.033, 84.038, 84.063, 84.268 Award year:2022 Corrective Action Plan: An external consultant (Higher Education Assistance Group) was contracted to bring current ...

Finding number: 2022-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster CFDA #: 84.007, 84.033, 84.038, 84.063, 84.268 Award year:2022 Corrective Action Plan: An external consultant (Higher Education Assistance Group) was contracted to bring current NVU?s required reporting for enrollment and student program status changes through the Spring 2022 term. This work was complete September 9. Letters/Notifications were issued to United Educators (August 10) and impacted students (week of September 5). Ongoing, NVU has received support from the registrar at our sister institution Community College of Vermont (CCV). CCV?s registrar has coordinated with the National Student Clearinghouse and submitted the first of term enrollment file for Fall 2022 on 10/3/22. NVU plans to hire a registrar soon and ongoing enrollment reporting will fall within the responsibilities of this new hire. Additionally, the Vermont State Colleges System registrar team will perform monthly checks to confirm that enrollment reporting for NVU has been completed. Timeline for Implementation of Corrective Action Plan: September 2022 Contact Person Sharron Scott, CFO

View Audit 28359

Finding 32366 (2022-004)

Significant Deficiency 2022

Beaufort County

NC

Eligibility

Finding 2022-004 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored o...

Finding 2022-004 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, work number searches, register of deeds search, documented resources of income, and ensure those amounts agree to information entered in NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

View Audit 27610

Finding 32365 (2022-003)

Significant Deficiency 2022

Beaufort County

NC

Eligibility Reporting

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the pa...

Finding 2022-003 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Staff will be trained on state communications as it relates to applicants' benefits and the importance of sharing information with all areas which the participant receives benefits. Currently the lead worker manages the notifications received to ensure timely processing of SSI terminations. Agency processes have been reviewed to monitor SSI terminations to prevent recertifications from becoming overdue. " Proposed completion date: "Training will be provided the week of November 7, 2022, to review findings and corrective action items. State communications will continue to be monitored. One (1) technical error cited for an untimely SSI Exparte Review was for a prior fiscal year. "

View Audit 27610

Finding 32364 (2022-002)

Significant Deficiency 2022

Beaufort County

NC

Eligibility

Finding 2022-002 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored o...

Finding 2022-002 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure worker is knowledgeable of policy requirements. Training will also be provided to ensure all files include online verifications, documentation of resources of income, and ensuring those amounts match information entered into NCF AST. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were four (4) technical errors cited with a review date from a prior fiscal year.

View Audit 27610

Finding 32363 (2022-001)

Significant Deficiency 2022

Beaufort County

NC

Eligibility Internal Control / Segregation of Duties

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored ...

Finding 2022-001 Name of contact person: Amy Alligood, Income Maintenance Administrator Corrective Action: "Supervisors will be second partying records internally to ensure accuracy of cases. Applications will be reviewed and recertifications will be monitored on a rotation basis. Findings from second party reviews will be reviewed with the worker to monitor a pattern for errors and will review policy guidelines to ensure the worker is knowledgeable of policy requirements. Training will be provided to ensure all files have accurate information entry to include correct household composition and correct income calculations. Supervisors will provide training to ensure workers are aware of proper documentation required to support eligibility decisions. Checklists have been established to include errors cited during audit. Checklists are to be completed at applications and recertifications. " Proposed completion date: Training will be provided the week of November 7, 2022, to review findings and corrective action items. Trainings will continue every week to review policy changes, NCF AST updates as well as common errors that may be found during second party reviews. There were six ( 6) technical errors cited with a review date from a prior fiscal year.

View Audit 27610

Finding 32361 (2022-001)

Material Weakness 2022

Strong-Huttig School District

AR

Equipment & Real Property Management Procurement, Suspension & Debarment § 200.313

The Strong - Huttig School District is committed to addressing and correcting these findings. The District will contact the Arkansas Division of Elementary and Secondary Education for guidance regarding this matter and implement proper controls over program expenditures. The District will also ensur...

The Strong - Huttig School District is committed to addressing and correcting these findings. The District will contact the Arkansas Division of Elementary and Secondary Education for guidance regarding this matter and implement proper controls over program expenditures. The District will also ensure all capital asset records are updated, and maintained moving forward. During the 2021-2022 school year the Bookkeeper and the Superintendent's Administrative Assistant both retired. Unfortunately the incoming replacements did not get a chance to train with them prior to their departure. Institutional knowledge, files, information, and procedures that should have been transferred to the new employees did not happen as planned. Our goal as a district is to ensure proper training for new employees, and administrative procedures and processes will be transferred better in the future.

View Audit 27784

Finding 32356 (2022-002)

Significant Deficiency 2022

Viroqua Area School District

WI

Questioned Costs Cash Management Matching / Level of Effort / Earmarking

2022-002 ? Education Stabilization Fund ? Prevailing wage rate requirements Condition: There was one Education Stabilization Fund construction project performed by a contractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $33,000. There was not a prevailing w...

2022-002 ? Education Stabilization Fund ? Prevailing wage rate requirements Condition: There was one Education Stabilization Fund construction project performed by a contractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $33,000. There was not a prevailing wage clause in the contract and certified payrolls were not received. Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts, subject to wage rate requirements, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Cause: The District was not aware that wage rate requirements applied to the construction project until after it was completed. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $33,000 Auditor?s Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Grantee Response: The District will comply with the wage rate requirements for the Education Stabilization Fund going forward. Contact Person: Michael Brendel Anticipated Completion: June 30, 2023

View Audit 27330 Questioned Costs: $1

Finding 32355 (2022-001)

Significant Deficiency 2022

Thomas Health System, Inc.

WV

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions an...

Finding 2022-001 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number: 93.498 Criteria: All recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services. Condition and Context: The System did not complete the PRF reporting for Period 2 in accordance with the U.S. Department of Health and Human Services guidance due to errors in the underlying data that lead to errors in the Period 2 report that was submitted. In the period 2 Submission, the System reported $2,283,650 of COVID-19 expenses, but failed to reduce the expenses by amounts reimbursed by other sources. Management updated their policies and procedures prior to Reporting Period 3 to address this issue. The System had $42,620,438 of lost revenue through Period 2 reporting, and has received $17,690,624 in PRF payments. Corrective Action Plan Corrective Action Planned: Thomas Health System, Inc. and its subsidiaries agrees with the finding, and policy and procedures were updated before reporting Period 3. Period 3 and 4 reporting were completed in accordance with the U.S. Department of Health and Human Services most guidance. The System received a notice from the Department of Health & Human Services dated December 29, 2022 that HRSA's Division of Financial Integrity has determined that the findings cited in the Single Audit Report for fiscal year October 1, 2020 through September 30, 2021 has been satisfactorily resolved. Name of Contact Person Responsible for Corrective Action: Timothy Skeldon, Chief Financial Officer, 4605 MacCorkle Ave SW, South Charleston, WV 25309 Anticipated Completion Date: Completed September 30, 2022

View Audit 28447

Finding 32354 (2022-002)

None 2022

Consolidated High School District 230

IL

Reporting

Finding Synopsis: During the audit, it was noted that the District did not always file expenditure reports within the stated time period for its Title I - Low Income Program. Action Steps: The District will implement an internal procedure to ensure proper filing within 20 days of quarter end to be i...

Finding Synopsis: During the audit, it was noted that the District did not always file expenditure reports within the stated time period for its Title I - Low Income Program. Action Steps: The District will implement an internal procedure to ensure proper filing within 20 days of quarter end to be in reporting compliance. Anticipated Date of Completion: June 30, 2023. Name of Contact Person: Tera Wagner. Management Response: Management concurs with the finding.

View Audit 27455

Finding 32353 (2022-002)

Material Weakness 2022

Spooner Health System

WI

Questioned Costs Internal Control / Segregation of Duties Allowable Costs / Cost Principles

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32352 (2022-003)

Material Weakness 2022

Spooner Health System

WI

Material Weakness Reporting Internal Control / Segregation of Duties

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are corr...

2022-003 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the System review the Provider Relief Fund reporting guidelines to make sure the amounts claimed are in line with the guidelines. We also recommend a review take place to make sure all amounts claimed are correctly calculated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. Based on the updated lost revenue numbers the System?s lost revenue would have increased from what was reported in the Phase 1 PRF report. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in future reporting periods. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255

Finding 32351 (2022-004)

Significant Deficiency 2022

Spooner Health System

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit findi...

2022-004 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend that management review the Provider Relief Fund guidelines to make sure amounts requested for reimbursement are in line with the guidelines and tie back to support. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The System will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. However, it is noted that there was sufficient lost revenue to support the PRF distributions received. Name(s) of the contact person(s) responsible for corrective action: Rebecca Busch, CFO Planned completion date for corrective action plan: We look to HRSA for guidance on how to correct the Period 1 report or will correct the error in a future reporting period. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Rebecca Busch, CFO at 715-939-1732.

View Audit 27255 Questioned Costs: $1

Finding 32340 (2022-005)

None 2022

Thurston County Chamber of Commerce

WA

Questioned Costs Allowable Costs / Cost Principles § 200.405

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

View Audit 27061 Questioned Costs: $1

Finding 32339 (2022-004)

None 2022

Thurston County Chamber of Commerce

WA

Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

View Audit 27061

Finding 32338 (2022-003)

None 2022

Thurston County Chamber of Commerce

WA

Internal Control / Segregation of Duties Subrecipient Monitoring

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

View Audit 27061

Finding 32337 (2022-002)

Material Weakness 2022

Thurston County Chamber of Commerce

WA

Procurement, Suspension & Debarment

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Resp...

CORRECTIVE ACTION PLAN Finding 2022-001 Internal Control over Bank Reconciliation and Vendor Invoice Management Response: Management agrees with this recommendation and have taken steps to implement proper review and documentation for bank reconciliations and vendor invoice approvals. Person Responsible: President/CEO, Finance Officer, and Program Managers Finding 2022-02 Debarred and Suspended Vendors Management Response: Management agrees with this recommendation and have taken steps to develop and implement proper internal controls. Person Responsible: Finance Officer and Program Managers Finding 2022-03 Monitoring Subcontractor Performance Management response: Management agrees with the recommendation and have scheduled training for key personnel. Person Responsible: Program Managers Finding 2022-04 Written Approval of Subcontractors Management Response: Management agrees with this recommendation and have scheduled training for key personnel. Person Responsible: President/CEO and Program Managers Finding 2022-005 Indirect Cost Allocation ? Questioned Costs Management Response: Management agrees with the need for additional grant training, especially as it applies to calculating and allocating indirect costs. However, we do have issues with the classification of expenses within the original contract and hope we can reconcile those prior to the finalization of the grant award. Person Responsible: President/CEO Finance Officer

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