Corrective Action Plans

Finding 61306 (2022-002)

Significant Deficiency 2022

MS

Subrecipient Monitoring Cash Management Reporting

Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Marc Rowe Title: Executive Director B: Description of corrective action planned: The district will implement and strengthen its internal control systems over reporting and submitting its monthly claims for reim...

Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Marc Rowe Title: Executive Director B: Description of corrective action planned: The district will implement and strengthen its internal control systems over reporting and submitting its monthly claims for reimbursement to ensure claims are submitted within established reporting deadlines. C. Anticipated completion date of corrective action: June 30, 2023

View Audit 49973

Finding 61304 (2022-001)

Significant Deficiency 2022

Claremont McKenna College

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding: 2022-001: Reporting ? Significant Deficiency in Internal Control over Compliance Corrective Action Plan: Management agrees with the finding related to the timing of posting certain quarterly information to the College?s website within 10 days of the end of the quarter in which Education Sta...

Finding: 2022-001: Reporting ? Significant Deficiency in Internal Control over Compliance Corrective Action Plan: Management agrees with the finding related to the timing of posting certain quarterly information to the College?s website within 10 days of the end of the quarter in which Education Stabilization Funds were expended. To address this issue, management has instituted a reconciliation of the award amount to the reported expenditures and implemented regular checks of the College?s COVID-19 response website to ensure reports continue to be posted in a timely manner. The College has now expended all Education Stabilization Funds, so we do not anticipate any additional quarterly reports needing to be posted on the College?s website. Contact Person Responsible for Corrective Action: Vice President of Business, Chief Financial Officer Erin Watkins, and Director of Finance Jennifer Perez have implemented the corrective action plan. Anticipated Completion Date: Corrective action was completed by October 2022.

View Audit 50153

Finding 61303 (2022-002)

Significant Deficiency 2022

The Home for Little Wanderers

MA

Questioned Costs Allowable Costs / Cost Principles Cash Management

Views of Responsible Officials and Planned Corrective Action Management has engaged a 3rd party to review, recommend and implement improvements to the current billing and month end closing processes. This will include improved documented processes and procedures along with the needed training to b...

Views of Responsible Officials and Planned Corrective Action Management has engaged a 3rd party to review, recommend and implement improvements to the current billing and month end closing processes. This will include improved documented processes and procedures along with the needed training to be effectively implemented and continued. Responsible Official: Michael Nowlan, Interim EVP/CFO

View Audit 49907 Questioned Costs: $1

Finding 61302 (2022-004)

Material Weakness 2022

Ochsner Lsu Health System of North Louisiana

LA

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

Finding 2022-004: Internal control deficiency and noncompliance over the calculation of lost revenues attributable to coronavirus. Since the start of the Covid-19 pandemic, Ochsner LSU Health has coordinated efforts across multiple divisions throughout the organization to ensure compliance with the...

Finding 2022-004: Internal control deficiency and noncompliance over the calculation of lost revenues attributable to coronavirus. Since the start of the Covid-19 pandemic, Ochsner LSU Health has coordinated efforts across multiple divisions throughout the organization to ensure compliance with the Provider Relief Fund that included leveraging publicly available information, outside consultants, and an internal review prior to management sign off. Ochsner LSU Health will ensure that all calculations are documented with detail supporting information. An additional quality control measure will be implemented whereby Ochsner?s Internal Audit Department will perform a detailed review of the calculation including tracing all formulas to ensure accuracy prior to management sign-off. In addition, Ochsner LSU Health will work with HRSA to understand the most appropriate manner to correct this issue within the Provider Relief Fund in the subsequent portal submissions. Responsible Official: Lauri Walton, Ochsner LSU Assistant Vice President of Accounting and Steven Stiles, Ochsner Vice President of Reimbursement Anticipated Completion Date: September 30, 2023

View Audit 49970

Finding 61301 (2022-003)

Material Weakness 2022

Ochsner Lsu Health System of North Louisiana

LA

Questioned Costs Internal Control / Segregation of Duties Reporting

Finding 2022-003: Internal control deficiency and noncompliance over reporting of expenses attributable to coronavirus in the HRSA PRF Reporting Portal. Since the start of the Covid-19 pandemic, Ochsner LSU Health has coordinated efforts across multiple divisions throughout the organization to ensu...

Finding 2022-003: Internal control deficiency and noncompliance over reporting of expenses attributable to coronavirus in the HRSA PRF Reporting Portal. Since the start of the Covid-19 pandemic, Ochsner LSU Health has coordinated efforts across multiple divisions throughout the organization to ensure compliance with the Provider Relief Fund that included leveraging publicly available information, outside consultants, and an internal review prior to management sign off. An additional level of review will be implemented whereby Ochsner?s Internal Audit Department will preview the preliminary HRSA PRF Report from the PRF Reporting Portal prior to submission to ensure expenses are not duplicated. In addition, Ochsner LSU Health will work with HRSA to understand the most appropriate manner to correct this issue within the Provider Relief Fund Portal. Responsible Official: Lauri Walton, Ochsner LSU Assistant Vice President of Accounting and Steven Stiles, Ochsner Vice President of Reimbursement Anticipated Implementation Date: September 30, 2023

View Audit 49970 Questioned Costs: $1

Finding 61300 (2022-002)

Material Weakness 2022

Ochsner Lsu Health System of North Louisiana

LA

Reporting Internal Control / Segregation of Duties

Finding 2022-002: Internal control deficiency and noncompliance over amounts reported in the Schedule of Expenditures and Federal Awards (SEFA) Ochsner LSU Health will implement additional review and coordinated efforts across departments throughout the organization to ensure the SEFA contains accu...

Finding 2022-002: Internal control deficiency and noncompliance over amounts reported in the Schedule of Expenditures and Federal Awards (SEFA) Ochsner LSU Health will implement additional review and coordinated efforts across departments throughout the organization to ensure the SEFA contains accurate information in reporting of expenditures. Additionally, current applicable guidance will be reviewed again before finalization. Responsible Official: Lauri Walton, Ochsner LSU Assistant Vice President of Accounting Implementation Date: July 31, 2023

View Audit 49970

Finding 61299 (2022-002)

None 2022

Litchfield Community Unit School District No. 12

IL

Equipment & Real Property Management

2022-002 Condition: The District budgeted for and included items in capital outlay objects in both the general ledger and Illinois State Board of Education expenditure reports that were below the District's capitalization threshold of $5,000. Recommendation: The District should only include item...

2022-002 Condition: The District budgeted for and included items in capital outlay objects in both the general ledger and Illinois State Board of Education expenditure reports that were below the District's capitalization threshold of $5,000. Recommendation: The District should only include items greater than its $5,000 capitalization threshold in capital outlay objects in its general ledger, budgets, and expenditure reports filed with the Illinois State Board of Education. Management Response: The District will follow the District's capitalization policy in future budgeting. Anticipated Date of Completion: June 30, 2023

View Audit 49920

Finding 61298 (2022-001)

Significant Deficiency 2022

Cedar Lane Senior Living Community Ii, Inc.

MD

HUD Housing Programs Procurement, Suspension & Debarment Cash Management

Name and Number of Project: Cedar Lane Senior Living Community II, Inc. HUD Project Number 052-11449 Auditor/Audit Firm: PKF O?Connor Davies LLP Audit Period: December 31, 2022 Fi...

Name and Number of Project: Cedar Lane Senior Living Community II, Inc. HUD Project Number 052-11449 Auditor/Audit Firm: PKF O?Connor Davies LLP Audit Period: December 31, 2022 Finding 2022-001 ? Use of Project Funds Federal Assistance Listing Number Name of Federal Programs 14.155 Mortgage Insurance for the purchase or Refinancing of Existing Multifamily Housing Projects A. Comments on Finding and Recommendations Recommendation ? We recommend that management reconcile and repay intercompany activity in a timely manner. B. Actions Taken or Planned The Entity has instituted policies and procedures to reconcile and rectify intercompany activities timely and is working with their HUD representative to consolidate their Federal Programs which will rectify the issue and simplify the intercompany activity. C. Status of Corrective Action on Prior Findings N/A _______________________________ __________________ Signature Date Eric Golden, President and CEO Cedar Lane Senior Living Community II, Inc.

View Audit 49343

Finding 61296 (2022-002)

Significant Deficiency 2022

Milbank School District No. 25-4

SD

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

2022-002. Finding: Compliance Findings ? Reporting Response: The Business Manager is the contact person at this entity responsible for the corrective action plan for this comment. The COVID pandemic has caused problems for our School District. Due at approximately the same time were the extende...

2022-002. Finding: Compliance Findings ? Reporting Response: The Business Manager is the contact person at this entity responsible for the corrective action plan for this comment. The COVID pandemic has caused problems for our School District. Due at approximately the same time were the extended audit for June 30, 2022, the annual report for June 30, 2023, and the proposed budget for the 2023-2024 school year. The late filing was caused by multiple financial processes being completed simultaneously.

View Audit 49455

Finding 61294 (2022-002)

Significant Deficiency 2022

Catholic Housing Corporation of Lansford

PA

Significant Deficiency Internal Control / Segregation of Duties

2022-02 Audit Finding

View Audit 49342

Finding 61231 (2022-002)

Significant Deficiency 2022

East Georgia Healthcare Center, Inc.

GA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Federal Award Finding Internal Control Over Compliance / Compliance Finding ? Significant Deficiency 2022-002 East Georgia Healthcare Center (EGHC) acknowledges the discrepancies between key line items on the Period 1 Provider Relief Fund (PRF) portal submission and underlying supporting documenta...

Federal Award Finding Internal Control Over Compliance / Compliance Finding ? Significant Deficiency 2022-002 East Georgia Healthcare Center (EGHC) acknowledges the discrepancies between key line items on the Period 1 Provider Relief Fund (PRF) portal submission and underlying supporting documentation. As a result of the difficulties described in financial statement finding 2022-001, there were delays in revenue billings and financial reporting, which impacted monthly net revenues from patients used in the Period 1 lost revenue calculation. Subsequent to the Period 1 PRF portal submission, EGHC recalculated monthly net revenues from patients based on updated actual amounts. Calculated lost revenues using the updated monthly amounts were less than lost revenues reported per the Period 1 PRF portal submission. However, EGHC has identified additional expenditures attributable to COVID-19, which were incurred during the period of January 1, 2020 through June 30, 2021, that offset the difference in lost revenues per the Period 1 PRF submission and lost revenues calculated using updated actual net revenues from patients. Based on this, EGHC believes that any risk to the program would be mitigated through the identification of additional eligible expenditures for Period 1. EGHC intends to correct the lost revenues and expenditures reported for Period 1 on the Period 4 PRF portal submission, which is due March 31, 2023. Sincerely, Jill Sorrells Chief Financial Officer

View Audit 54464

Finding 61227 (2022-001)

Material Weakness 2022

West Independent School District

TX

Internal Control / Segregation of Duties

Recommendation: The District should ensure procedures are in place to provide for proper budget amendments. District's Response: The District will review existing procedures and adjust its budget before expenditure.

View Audit 52070

Finding 61226 (2022-005)

Material Weakness 2022

Mahaska County Hospital D/b/a Mahaska Health Partnership

IA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.327 § 200.328

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 an...

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a debt service reserve fund as bookkeeping accounts or as separate bank accounts. Condition: During 2022, the certificate of deposit that represented the debt service reserve fund matured and the proceeds were commingled with an existing money market fund. Planned Corrective Action: Management agrees with the finding and will deposit the required debt service reserve funds in a separate bank account. Planned Completion Date: June 30, 2023 Person Responsible: Daris Rosencrance, CFO

View Audit 50022

Finding 61225 (2022-004)

Material Weakness 2022

Mahaska County Hospital D/b/a Mahaska Health Partnership

IA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.327 § 200.328

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 an...

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the audited financial statements to be provided to the federal agency annually within 150 days of fiscal year-end, as well as quarterly internal financial statements. Condition: The Partnership did not submit the audited financial statements within the prescribed period or request an extension and did not submit any quarterly reports to the federal agency. The Partnership was not asked for the information after they failed to submit it. The audited financial statements are readily available to the federal agency through the federal clearinghouse website. Planned Corrective Action: Management agrees with the finding and are implementing procedures to ensure that the required financial reports are submitted in a timely manner in accordance with the terms and conditions of the federal award. Planned Completion Date: June 30, 2023 Person Responsible: Daris Rosencrance, CFO

View Audit 50022

Finding 61219 (2022-002)

None 2022

Pontiac Academy for Excellence

MI

Cash Management School Nutrition Programs Program Income

CORRECTIVE ACTION PLAN: The management company for the Academy will work with the Academy leadership to increase expenditures in a manner necessary to spend down the excess fund balance in an allowable and timely fashion. The spend down plan will include improvements to the food service program, in...

CORRECTIVE ACTION PLAN: The management company for the Academy will work with the Academy leadership to increase expenditures in a manner necessary to spend down the excess fund balance in an allowable and timely fashion. The spend down plan will include improvements to the food service program, including adding an additional food service support position. The number of salad bar offerings and daily hot breakfast options will be increased for all grade levels. The Academy will also explore allowable options for spending funds on supplies, equipment and initiatives that will create sustainable improvements to the food service program for future years. RESPONSIBLE DEPARTMENT: Finance department and Food Service department. RESPONSIBLE PERSONS: Melinda Benkovsky, VP of Finance Gwen Hovey, Food Service Coordinator PLANNED COMPLETION DATE (TBD OR DATE): June 30, 2023

View Audit 50021

Finding 61144 (2022-001)

Significant Deficiency 2022

Tuscarawas Valley Local School District

OH

School Nutrition Programs Subrecipient Monitoring Cash Management

Planned Corrective Action The district Food Service Director will verify and print supporting documentation to prove system-generated reports reconcile to the CRRS System a...

Planned Corrective Action The district Food Service Director will verify and print supporting documentation to prove system-generated reports reconcile to the CRRS System after data entry is completed. The Food Service Director will initial and date the reports upon completing and verifying the reconciliation. Anticipated Completion Date: 3/1/2023 Responsible Contact Person: Food Service Director

View Audit 49892

Finding 61133 (2022-003)

None 2022

Morehouse School of Medicine, Inc., Subsidiary and Affiliate

GA

Reporting

Name of Responsible Individual: Beatrice Raiford, Director Office of Sponsored Programs Corrective Action: We concur. We understand as noted in the terms of the grant agreement for the NCRN grant that performance reports are due quarterly. The performance report was submitted timely by the program...

Name of Responsible Individual: Beatrice Raiford, Director Office of Sponsored Programs Corrective Action: We concur. We understand as noted in the terms of the grant agreement for the NCRN grant that performance reports are due quarterly. The performance report was submitted timely by the program office through the required federal system; however, we failed to obtain confirmation of report submission as proof of timely submission. We will review our reporting processes for performance reporting to ensure receipt of confirmation. This confirmation will be included in our files as proof of compliance. Additionally, performance reporting confirmations will be submitted to the Office of Grants and Contracts as a further review for compliance. Anticipated Completion Date: January 31, 2023

View Audit 56656

Finding 61122 (2022-003)

Significant Deficiency 2022

City of Las Vegas

NV

Allowable Costs / Cost Principles Cash Management Reporting

Finding 2022-003: Internal Controls Over Financial and Performance Reporting ? Significant Deficiency Management Response and Planned Corrective Action This finding relates to the absence of a signature and date indicating a management review before submission for reimbursement as evidence of an int...

Finding 2022-003: Internal Controls Over Financial and Performance Reporting ? Significant Deficiency Management Response and Planned Corrective Action This finding relates to the absence of a signature and date indicating a management review before submission for reimbursement as evidence of an internal control. Management concurs that there was no signature and date reviewed for submissions related to the Disaster Grants ? Public Assistance program. Management will implement a process where all submissions to federal agencies will be signed and dated prior to submission as an indication of internal control over the approval process.

View Audit 49725

Finding 61118 (2022-004)

Significant Deficiency 2022

City of Las Vegas

NV

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-004: Federal Funding Accountability and Transparency Act for Housing Opportunities for Persons with AIDs Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for t...

Finding 2022-004: Federal Funding Accountability and Transparency Act for Housing Opportunities for Persons with AIDs Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for the Housing Opportunities for Persons with AIDs Program for three sub-awards was not submitted by the last day of the month following the month in which the sub-award was made, and three of the obligation dates reported were incorrect. The FFATA report was prepared and filed by the Neighborhood Services Administrator. Management will implement a process where Grant Coordinators will prepare the report and the Grant Administrator will review the information for accuracy and input the data into the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Neighborhood Services Administrator will review the report and file in a timely manner.

View Audit 49725

Finding 61111 (2022-005)

Significant Deficiency 2022

City of Las Vegas

NV

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2022-005: Federal Funding Accountability and Transparency Act for Community Development Block Grant Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for Community D...

Finding 2022-005: Federal Funding Accountability and Transparency Act for Community Development Block Grant Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for Community Development Block Grant Program for five sub-awards was not submitted by the last day of the month following the month in which the sub-award was made, and one of the obligation dates reported was incorrect. The FFATA report was prepared and filed by the Neighborhood Services Administrator. Management will implement a process where Grant Coordinators will prepare the report and the Grant Administrator will review the information for accuracy and input the data into the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Neighborhood Services Administrator will review the report and file in a timely manner. Responsible Personnel Gary Ameling, Chief Financial Officer

View Audit 49725

Finding 61109 (2022-032)

Material Weakness 2022

State of New Hampshire

NH

Reporting

View of Responsible Officials Corrective actions are currently in development to address the completeness and accuracy of HSEM?s federal reporting. Anticipated Completion Date: June 30, 2023 Contact Person: Matthew Hotchkiss, Financial Manager HSEM, 603-223-3624, Matthew.A.Hotchkiss@dos.nh.gov

View Audit 49723

Finding 61102 (2022-031)

Material Weakness 2022

State of New Hampshire

NH

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

View of Responsible Officials We concur. The Department has contracted with Myers & Stauffer (M&S) to conduct the periodic audits of all three of its Managed Care plans for State Plan Rate Year 2020. We anticipate the audits will be completed by August 2023. Anticipated Completion Date: September ...

View of Responsible Officials We concur. The Department has contracted with Myers & Stauffer (M&S) to conduct the periodic audits of all three of its Managed Care plans for State Plan Rate Year 2020. We anticipate the audits will be completed by August 2023. Anticipated Completion Date: September 2023 Contact Person: Shirley Iacopino

View Audit 49723

Finding 61101 (2022-030)

Material Weakness 2022

State of New Hampshire

NH

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

View of Responsible Officials We concur and have developed a corrective action plan in conjunction with Conduent. See attached plan. The SOC report will include auditing the change management of the quarterly NCCI edit checks. The auditing firm will also update the control objective 5 activities t...

View of Responsible Officials We concur and have developed a corrective action plan in conjunction with Conduent. See attached plan. The SOC report will include auditing the change management of the quarterly NCCI edit checks. The auditing firm will also update the control objective 5 activities to include a population of claims specifically with NCCI edits. Anticipated Completion Date: The completed 6/30/2023 SOC report. Contact Person: Roger Boissonneau, MMIS Director

View Audit 49723

Finding 61100 (2022-029)

Significant Deficiency 2022

State of New Hampshire

NH

Eligibility Matching / Level of Effort / Earmarking Subrecipient Monitoring

View of Responsible Officials 1. We concur. The Provider enrollment unit (PEU) is currently working on revalidations not completed and have a plan to deposition those providers while ensuring minimal disruption to member services and protecting limited provider networks disciplines such as the ment...

View of Responsible Officials 1. We concur. The Provider enrollment unit (PEU) is currently working on revalidations not completed and have a plan to deposition those providers while ensuring minimal disruption to member services and protecting limited provider networks disciplines such as the mental health network. I, the PEU administrator have been conducting biweekly meetings with Conduent and our business systems analyst to develop a plan and a systematic approach to revalidate all providers in the future. I am currently drafting a policy and procedure memo that will outline the new process for revalidations so that revalidations will be timely and complete in the future. Once the new process is implemented, I intend to review revalidations with Conduent at our biweekly provider enrollment meetings to ensure the revalidation process is conducted in a timely fashion and the implemented process for revalidations is working in that all revalidations are performed timely. As for the past due revalidations, the PEU anticipates all past due provider revalidations, prior to the PHE, to be either completed or be terminated by the beginning of March 2023. 2. We partially agree. The attestation signed in 2012 does not have an expiration and there is no Federal regulation or State law that requires this to be renewed, however, based on the finding last year, the Office of Medicaid Services did a new attestation in 2022. The 2022 attestation also does not have an end date and is not required to be renewed at any time. The attestation ends when the agreement is terminated by either parties. Anticipated Completion Date: March 2023 Contact Person: Stephanie Aulis

View Audit 49723

Finding 61095 (2022-028)

Material Weakness 2022

State of New Hampshire

NH

Matching / Level of Effort / Earmarking Reporting

View of Responsible Officials The Department of Energy is currently in contact and working with representatives from the US DHHS to resolve the fact that the SF-425 report is not available for updating at this time for grant #2001NHE5C3. It must be made available for updating within the HHS reportin...

View of Responsible Officials The Department of Energy is currently in contact and working with representatives from the US DHHS to resolve the fact that the SF-425 report is not available for updating at this time for grant #2001NHE5C3. It must be made available for updating within the HHS reporting site by DHHS in order for Grantees to edit and submit a report. Corrective Action We will continue to work with US DHHS for any grant awarded to us that has this same reporting issue in the future. Anticipated Completion Date: Ongoing Contact Person: Jane Lemire Business Administrator IV (PT)

View Audit 49723

Corrective Action Plans

Filters