Corrective Action Plans

Finding 12855 (2022-002)

Significant Deficiency 2022

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.

View Audit 17759

Finding 12854 (2022-001)

Significant Deficiency 2022

Elm Hill Water District

MA

Internal Control / Segregation of Duties Significant Deficiency

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 17759

Finding 12853 (2022-001)

Significant Deficiency 2022

Maine Technology Insititute

ME

Procurement, Suspension & Debarment

Responsible Party: Gregory N. Lee, Director of Finance and Administration, Anticipated Completion Date: 11/30/2022; Subsequent to the funding of awards, management initiated a search of the SAM database of exclusions and found that no awardees were on that list. This was completed October 7, 2022. F...

Responsible Party: Gregory N. Lee, Director of Finance and Administration, Anticipated Completion Date: 11/30/2022; Subsequent to the funding of awards, management initiated a search of the SAM database of exclusions and found that no awardees were on that list. This was completed October 7, 2022. Future contracts for the award of federal funds will include a clause requiring a recipient to attest that they are not suspended or debarred from participating in transactions covered under the Federal Acquisition Regulation. Contracts will also indicate that the recipient consents to verification of all provided information. Management will also be undertaking a search of the SAM database of exclusions prior to the award of any funds. This step will be incorporated into the policies and procedures around the award approval process and staff will be provided with training to perform such a search.

View Audit 17758

Finding 12850 (2022-002)

Material Weakness 2022

Moniteau School District

PA

Questioned Costs Procurement, Suspension & Debarment

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it?s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) and 2 CFR 200.320(a)(2)(i) of the Uniform Guidan...

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it?s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) and 2 CFR 200.320(a)(2)(i) of the Uniform Guidance, and 24 PS 8.807.1. The timeframe for completion of this process will commence and be finalized during the District?s 2023-2024 fiscal year and will be revised on an ongoing basis as required by new policy directives from oversight agencies. In addition, management will respond with additional measures considered necessary by the Pennsylvania Department of Education upon review of this finding and management?s corrective action plan.

View Audit 17757 Questioned Costs: $1

Finding 12849 (2022-003)

Material Weakness 2022

Moniteau School District

PA

Procurement, Suspension & Debarment

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management of the School District, as a matter of policy, will implement the six (6) recommended affirmative action steps to ensure compliance with Section 2 CFR 200.321(a) of the Uniform Guidance. The timeframe for completion of this process will commence and b...

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management of the School District, as a matter of policy, will implement the six (6) recommended affirmative action steps to ensure compliance with Section 2 CFR 200.321(a) of the Uniform Guidance. The timeframe for completion of this process will commence and be finalized during the District?s 2023-2024 fiscal year.

View Audit 17757

Finding 12848 (2022-001)

Material Weakness 2022

Moniteau School District

PA

Questioned Costs Procurement, Suspension & Debarment

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it?s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. The timeframe for comp...

MANAGEMENT?S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it?s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. The timeframe for completion of this process will commence and be finalized during the District?s 2023-2024 fiscal year and will be revised on an ongoing basis as required by new policy directives from oversight agencies. In addition, management will respond with additional measures considered necessary by the Pennsylvania Department of Education upon review of this finding and management?s corrective action plan.

View Audit 17757 Questioned Costs: $1

Finding 12832 (2022-002)

Material Weakness 2022

National Council of Urban Indian Health

DC

Cash Management Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.305

Views of Responsible Officials and Planned Corrective Actions: During this fiscal year, management experienced a turnover in the financial functions as well as new staffing and a new Director of Finance. In addition, the organization changed drastically in size and scope, thereby going through a sub...

Views of Responsible Officials and Planned Corrective Actions: During this fiscal year, management experienced a turnover in the financial functions as well as new staffing and a new Director of Finance. In addition, the organization changed drastically in size and scope, thereby going through a substantial adjustment period. Corrective actions: 1. Management hired an Assistant Director of Finance in order to share the workload, add an extra layer of review for all documentation, account reconciliations, finance staff oversight, and banking functions. 2. Management hired an Associate VP of the Programs and Operations Division which has oversight over the Finance Department. 3. Monthly reconciliations and reviews and approval processes have been put in place to ensure proper recording of all expenses, revenues, and accompanying Federal Fund drawdowns and AP payments. 4. The federal department this occurred within was notified and the funds were spent on costs incurred in the next fiscal year.

View Audit 17751

Finding 12825 (2022-001)

Material Weakness 2022

West Central Illinois Area Agency on Aging

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed and signed by the director or assistant director of the agency before being su...

Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed and signed by the director or assistant director of the agency before being submitted to the grantor. A report comparing the cash request amounts made to the grantor to the general ledger has been implemented effective January 31,2023. A procedure is also being developed to periodically monitor adherence to various grant requirements, as well as the development of documentation to support personnel activity tied to grants. The fiscal department intends to implement these effective June 30, 2023.

View Audit 17744

Finding 12824 (2022-007)

None 2022

City of Las Vegas

NM

Internal Control / Segregation of Duties Special Tests & Provisions § 200.318

Finding Number: 2022-007 Finding : Premium Pay Corrective Action Taken or To Be Taken: Recommend the City create internal controls to ensure that they review federal and state regulations prior to disbursements to ensure costs are allowable. We also recommend the City work with elected officials to ...

Finding Number: 2022-007 Finding : Premium Pay Corrective Action Taken or To Be Taken: Recommend the City create internal controls to ensure that they review federal and state regulations prior to disbursements to ensure costs are allowable. We also recommend the City work with elected officials to create a corrective action plan to recoup the federal funds. Agency Response: Does agency agree with finding? If no or partially, please explain reason(s) why? Initially premium payments were only made to paid staff. Management was unaware of the provisions in reference to elected officials not being able to receive premium pay so they requested premium pay for the elected officials at a later date. The City Manager has sent an email to all elected officials requesting that the funds be reimbursed to the City. At this time (4) four of the (6) six elected officials have reimbursed the City and the others have committed to do so as well. Additional Comments:

View Audit 17742

Finding 12823 (2022-001)

Significant Deficiency 2022

Pennsylvania Institute of Technology and Subsidiaries

PA

Subrecipient Monitoring Reporting

FINDING 2022-001: COVID-19 - Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425E Student Aid Portion/ 84.425F Institutional Portion Recommendation: The College should assign an individual to track reporting requirements of awards to ensure the College is in compliance an...

FINDING 2022-001: COVID-19 - Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425E Student Aid Portion/ 84.425F Institutional Portion Recommendation: The College should assign an individual to track reporting requirements of awards to ensure the College is in compliance and identify a designated reviewer for the information posted to the College?s website. The College should post the information required under the Student Aid Portion to its website in accordance with the ED guidelines. Action Taken: The College has updated its website on October 15, 2022 with the information regarding the Student Aid Portion distributed under HEERF II and III to its website in accordance with the ED guidelines. The College President and Director of Financial Aid will be responsible for ensuring that the website posting deadline has been met by monitoring this activity each quarter. Responsible Individual for Corrective Action: Laura Blomgren, Director of Student Financial Aid Completion Date: October 15, 2022

View Audit 17737

Finding 12810 (2022-002)

Significant Deficiency 2022

Milwaukee Area Technical College

WI

Student Financial Aid Reporting

Finding No. 2022-002 ? Report Filed After Due Date Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: By October 1 the institution should submit its...

Finding No. 2022-002 ? Report Filed After Due Date Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: By October 1 the institution should submit its ED Form 646-1, Fiscal Operations Report, and Application to Participate (FISAP) that includes the Fiscal Operations Report for the preceding award year and the Application to Participate for the upcoming award year (FWS, FSEOG 34 CFR 673.3; Fiscal Operations Report and Application to Participate Instructions). Condition / Context: The FISAP for award year 2021-2022 was filed on October 12, 2022. Our sample was statistically valid. Cause: As MATC approached the deadline for FISAP submission, responsible MATC personnel were not aware of the outstanding reporting items and the immediate need to employ an alternative plan to ensure the timely submission of the FISAP. Questioned Costs: Unknown Effect: This electronic report is submitted annually to receive funds for the campus-based programs. The institution uses the Fiscal Operations Report portion to report its expenditures in the previous award year and the Application to Participate portion to apply for the following year. Delays in filing of this report could result in delays with subsequent year funding. Recommendation: MATC should implement a reporting calendar, including deadlines for draft, review and approval of the FISAP to ensure timely filing. District Response: MATC agrees with the finding and has developed, documented and implemented a process and calendar to ensure timely completion of the annual FISAP. Al Pinckney, Executive Director of Financial Aid 12/6/2022

View Audit 17732

Finding 12809 (2022-003)

Significant Deficiency 2022

Milwaukee Area Technical College

WI

Questioned Costs Student Financial Aid Period of Performance

Finding No. 2022-003 ? R2T4 Return Calculation Errors Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: For returns of Title IV Funding when a stud...

Finding No. 2022-003 ? R2T4 Return Calculation Errors Repeat Finding: No ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: For returns of Title IV Funding when a student does not complete the enrollment period for which funds were disbursed, the amount of earned Title IV grant or loan assistance is calculated by determining the percentage of Title IV grant or loan assistance that has been earned by the student and applying that percentage to the total amount of Title IV grant or loan assistance that was or could have been disbursed to the student for the payment period or period of enrollment as of the student's withdrawal date. Standard term-based institutions must always use the payment period as the basis for the determination. The unearned amount of Title IV assistance to be returned is calculated by subtracting the amount of Title IV assistance earned by the student from the amount of Title IV aid that was disbursed to the student as of the date of the institution's determination that the student withdrew (34 CFR 668.22(e)). Condition / Context: The auditor selected 21 unenrolled students who had Title IV returns for testing. For each student selected, the return amount was incorrectly calculated because the payment period was not used as the basis for the determination. Our sample was statistically valid. Cause: Unauthorized break periods and start dates were used to determine the base period for calculation. MATC's review process was not effective to detect and correct this error. Staff responsible for calculating R2T4 returns were not properly trained in the requirements. Questioned Costs: $5,097 Effect: MATC has determined that a total of 425 returns were incorrectly calculated, with an estimated net error of $5,097. Recommendation: We recommend MATC re-evaluate its review process for Title IV returns, and provide additional training for management and staff to ensure the calculations and compliance requirements are understood and that control processes are operating effectively to ensure proper returns. District Response: MATC agrees with the finding and has developed, documented and implemented a process and correct the student record errors, provide updated training and update R2T4 procedures to ensure proper calculation going forward. Al Pinckney, Executive Director of Financial Aid 12/6/2022

View Audit 17732 Questioned Costs: $1

Finding 12808 (2022-004)

Significant Deficiency 2022

Milwaukee Area Technical College

WI

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Finding No. 2022-004 ? Reporting Discrepancies - Enrollment Repeat Finding: 2021-001 ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: Institutions are required to re...

Finding No. 2022-004 ? Reporting Discrepancies - Enrollment Repeat Finding: 2021-001 ALN and Program: 84.007; 84.033; 84.063; 84.268 ? Student Financial Assistance Cluster Award Amount: $46,751,524 Award Number: N/A Award Year: 7/1/2021-6/30/2022 Criteria: Institutions are required to report enrollment information under the Pell grant and the Direct and FFEL loan programs via the NSLDS (OMB No. 1845-0035). Institutions must review, update and verify student enrollment statuses, program information, and effective dates that appear on the Enrollment Reporting Roster file or on the Enrollment Maintenance page of the NSLDS Professional Access (NSLDSFAP). Condition / Context: We selected a sample of 25 Pell and Direct Loan students from the institution's records that had a reduction or increase in attendance levels, graduated, withdrew, dropped out or enrolled but never attended during the audit period. We compared the data in the students' NSLDS Enrollment Detail to the students' academic files and other institutional records and verified that the institution is accurately reporting the significant Campus-Level and Program-Level enrollment data elements that ED considers high risk. Of the 25 sampled, 10 had discrepancies between the status documented in MATC's institutional records and the status reported on the NSLDS. Our sample was not statistically valid. Cause: In April 2021, the National Student Clearinghouse made a change to its reporting process, which resulted in errors in MATC's data uploads. MATC has begun the process of testing and correcting its process, but this was not completed as of June 30, 2022. MATC believes this update error has caused the continued discrepancies between MATC and the NSLDS. Questioned Costs: Unknown Effect: The administration of the Title IV programs depends heavily on the accuracy and timeliness of the enrollment information reported by institutions. Incorrect reporting of enrollment status could result in incorrect distribution of Title IV funds to institutions or individuals. Recommendation: We recommend MATC continues its review process for enrollment statuses, and provide additional training for management and staff to ensure the correct statuses are reported and that control processes are operating effectively to ensure proper returns. District Response: The Office of the Registrar has developed and is implementing an action plan to ensure correct reporting through the National Clearinghouse and NSLDS. The process includes additional staff training, review and update of the submissions process and schedule and enlisting support from specific contacts at the Clearinghouse. These steps were completed by September 2022. Additional steps, including review of the reporting setup the SIS system with the IT department, discussing and resolving existing issues with the Clearinghouse, performing checks of individual current and prior year students to identify and correct additional gaps, incorporating a regular review of a sample of students for proper reporting and hiring additional staff for reporting enrollment ? all to be completed by December 2022. Beginning in 2023, staff will also create and submit an additional report to the Clearinghouse for each submission of graduates and creating a position to lead enrollment reporting. Dr. Sarah Adams, Dean of Enrollment Services 12/6/2022

View Audit 17732

Finding 12771 (2022-004)

Significant Deficiency 2022

Charles County Public Schools

MD

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.308 § 200.309 § 200.403

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period o...

U.S. Department of Education 2022-004 Special Education Cluster ? Assistance Listing No. 84.027 and 84.173 Recommendation: The Board should review and enhance internal controls and procedures to ensure that it charges expenditures to the program that are incurred within an award?s allowable period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Office of Fiscal Services will improve internal controls over the procedures that ensure expenditures to a program are incurred within an award?s allowable period of performance. During the year-end close out process, the Lead Restricted Funds Accountant will review the close out of all restricted funds against the grant periods. If expenditures are inadvertently incurred outside of the grant period, the expenditures will be reclassified to an existing like grant if allowable or to the operating budget. If the Lead Restricted Funds Accountant is unavailable or has closed out grants themselves, this review will be done by the Budget Manager. The school district will implement a new financial system in July 2023. The implementation of this new system will allow for more automated internal controls. Name(s) of the contact person(s) responsible for corrective action: Rosa Aquino and/or Sherri Fisher-Davis Planned completion date for corrective action plan: December 31, 2022

View Audit 17731

Finding 12770 (2022-001)

Significant Deficiency 2022

Humility Homes and Services, Inc.

IA

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Corrective action taken: Management will implement policies and procedures to ensure reports are reviewed and submitted timely in accordance with grant requirements.

View Audit 17728

Finding 12769 (2022-005)

Significant Deficiency 2022

Northwest Harvest

WA

In July of 2022, NWH implemented cost numbers in its payroll processing system for staff to provide appropriate tracking of costs and time allocated to grants. NWH is able to provide reports and appropriate documentation to comply with federal funding grant requirements.

View Audit 17727

Finding 12768 (2022-004)

Significant Deficiency 2022

Northwest Harvest

WA

Procurement, Suspension & Debarment

NWH has hired a consultant to finalize its draft procurement policy. The policy is anticipated to be adopted by April of 2023 and comply with procurement standards set forth in 2 CFR sections 200.318 through 200.326 and ensure that contractors hired are not suspended or debarred or otherwise exclude...

NWH has hired a consultant to finalize its draft procurement policy. The policy is anticipated to be adopted by April of 2023 and comply with procurement standards set forth in 2 CFR sections 200.318 through 200.326 and ensure that contractors hired are not suspended or debarred or otherwise excluded from participating in federally funded programs. New and existing procurement vendors that NWH conducted business with during FY 2022 have been verified with the System for Award Management (SAM) debarred or suspended vendor verification. The verification was completed 01/17/2023, with no vendors suspended or disbarred.

View Audit 17727

Finding 12765 (2022-001)

None 2022

Cicero Commons Senior Housing Development Fund Company, Inc.

NY

HUD Housing Programs

Finding 2022-001: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Recommendation: Our auditors recommended that we make the remaining $1,910 deposit into the reserve for replacements when cash flow was sufficient. Action Taken: Lucille Manor Apartments ma...

Finding 2022-001: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Recommendation: Our auditors recommended that we make the remaining $1,910 deposit into the reserve for replacements when cash flow was sufficient. Action Taken: Lucille Manor Apartments made the required payment was made in July 2022. Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821. Completion Date: July 2022

View Audit 17713

Finding 12728 (2022-002)

Significant Deficiency 2022

Hot Springs County

WY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

Audit Finding 2022-002 Finding Lack of Written Policies and Procedures over Federal Awards ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Corrective action plan in progress Corrective Action Plan In response to the finding...

Audit Finding 2022-002 Finding Lack of Written Policies and Procedures over Federal Awards ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Corrective action plan in progress Corrective Action Plan In response to the finding, the County is in the process of developing written policies and procedures relative to internal controls over federal awards, to help achieve: - County wide consistency over compliance regulations and standards - Decrease the risk of grant agreement noncompliance - Reduce the risk of undetected errors in processing of financial transactions relative to federal awards. Steps taken include: - Familiarization of requirements in 2 CFR 200.303 - Obtain draft examples of policies and procedures adopted by other Counties - Discussion with governance and county attorney regarding development and adoption of policies and procedures In addition, the County is continuing to suggest departments implement effective internal control structures to - Protect assets against theft and waste - Ensure accurate and reliable operating and accounting data The conditions noted in this finding were previously reported in finding 2021-002 Completion Date Estimated June 2023 - policy written, approved by Commissioners, and disseminated ot departments Training - ongoing County Contact Becky Kersten, County Clerk

View Audit 17708

Finding 12727 (2022-001)

Significant Deficiency 2022

Hot Springs County

WY

Internal Control / Segregation of Duties

Audit Finding 2022-001 Finding Segregation of Duties ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Ongoing Monitoring & Education Corrective Action Plan The County understands that no one individual should handle or domin...

Audit Finding 2022-001 Finding Segregation of Duties ALN Number 21.027 ALN Name Coronavirus State & Local Fiscal Recovery Funds Questioned Costs $0 County Response Concur Status Ongoing Monitoring & Education Corrective Action Plan The County understands that no one individual should handle or dominate transactions from initiation to posting in the general ledger as well as having access to assets and the accounting records. By State statute, the County's Clerk and Treasurer offices are set up to segregate the County general ledger transactions as such: - disbursement of County funds initiated in Clerk's office - receipt of County completed in Treasurer's office. In addition, the County continues to suggest departments implement effective internal control structures to: - Protect assets against theft and waste - Ensure accurate and reliable operating and accounting data - Establish written policies and procedures to aid in the implementation of segregation of duties for their respective areas of responsibility The conditions noted in this finding were previously reported in findings 2021-001 Completion Date Ongoing County Contact Becky Kersten, County Clerk

View Audit 17708

Finding 12725 (2022-001)

None 2022

Rodeo Senior Apartments, Inc.

CA

Questioned Costs HUD Housing Programs Reporting

Finding Number Planned Corrective Action Anticipated Completion Date Responsible Contact Person 2022-001 Management Agent will refund all amounts owed to property per Audit finding. Going forward only HUD approved fees will be charged to property. 12/31/2022 Bipin Patel ? Accounting Manager

View Audit 17646 Questioned Costs: $1

Finding 12724 (2022-002)

Significant Deficiency 2022

Sma Healthcare, Inc.

FL

In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in Novemb...

In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in November of 2018, we added presence of the financial assessment form to the compliance review process. The compliance percentage of that measure is reported monthly to staff and also to the Quality Performance Review Committee of the board of directors. Our internal tracking indicates compliance now exceeds 98%. We will continue the monitoring and education efforts and expect to move toward full compliance.

View Audit 17581

Finding 12723 (2022-001)

Significant Deficiency 2022

Sma Healthcare, Inc.

FL

In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in Novemb...

In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in November of 2018, we added presence of the financial assessment form to the compliance review process. The compliance percentage of that measure is reported monthly to staff and also to the Quality Performance Review Committee of the board of directors. Our internal tracking indicates compliance now exceeds 98%. We will continue the monitoring and education efforts and expect to move toward full compliance.

View Audit 17581

Finding 12722 (2022-001)

Material Weakness 2022

Legacy Health

OR

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

Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund porta...

Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund portal. Additionally, Legacy claimed expenses that were duplicated within the reporting portal. The general distribution report for Legacy Health for Period 1 shows $35,760,843 in expenses applied against the PRF funds in the PRF portal report for Legacy as a consolidated entity. Separately, the stand-alone reports for targeted funds received by Emanuel Hospital & Health Center for Period 1, Legacy Silverton Medical Center for Period 1, Legacy Clinics, LLC for Period 1, and Legacy Meridian Park Hospital for Period 2 also include expenses totaling $12,291,293 that are included in the $35,760,843 listed in the consolidated report above. This results in duplicate reporting of the same expenditures. During testing over reporting and allowability it was observed that the lost revenues attributable to Coronavirus were reported in both the parent entity?s PRF reports on the general distribution payments and the subsidiary entities? PRF reports on the targeted distribution payments (i.e., lost revenues were duplicated). Lost revenues shown on the subsidiary reports as available to be applied against PRF that related to lost revenues also reported in the parent entity?s report were related to Emanuel Hospital & Health Center for Period 1 in the amount of $27,106,110 and Legacy Silverton Medical Center for Period 1 in the amount of $10,269,349. Actions Taken and Status As noted within the portal filing summary, for reporting period 1, Legacy consolidated COVID-19 expenses ($35,760,843) plus lost revenue ($150,037,450) totaled $185,798,293. Payments from the PRF totaled $89,818,954. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the questioned costs above. Therefore, management believes no repayment of PRF funds received would be required. Further, management considered the finding. Reporting for the Legacy parent reporting entity was based on the ?Post-Payment Notice of Reporting Requirements (6/11/21)?, which includes the following requirement: ?Reporting entities will submit consolidated reports.? Neither the methodology utilized by Legacy or application of the methodology advocated by KPMG result in repayment of any of the funds received from the PRF. Management is implementing a process to identify and resolve situations in which reporting requirements are inconclusive, in conflict, or ambiguous. Outside subject matter expertise will be accessed as needed. Person responsible for the implementation of the corrective action plan: Tom Haywood Legacy Health 1919 NW Lovejoy St Portland OR 97219 503-415-5793 thaywood@lhs.org

View Audit 17558 Questioned Costs: $1

Finding 12721 (2022-003)

Significant Deficiency 2022

The Inner Voice, Inc.

IL

Reporting Internal Control / Segregation of Duties

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verificati...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verification with funders should be performed as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name(s) of the contact person(s) responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.

View Audit 17548

Corrective Action Plans

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