Corrective Action Plans

Finding 12207 (2022-001)

Significant Deficiency 2022

MN

Internal Control / Segregation of Duties

Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Spencer Aune, Business Manager Corrective Action Planned Management will attempt to monitor transactions. and structure the duties of office personnel to help ensure as much segrega...

Finding Number: 2022-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Spencer Aune, Business Manager Corrective Action Planned Management will attempt to monitor transactions. and structure the duties of office personnel to help ensure as much segregation of duties as possible within the District's staffing limitations and funding constraints. Anticipated Completion Date Ongoing.

View Audit 16347

Finding 12203 (2022-001)

None 2022

School of Excellence in Education

TX

Internal Control / Segregation of Duties Special Tests & Provisions

Summary Description: During the summer the Campus Testing Coordinator (Instructional Coach) for the campus resigned. Although the testing coordinators received testing security training that included the required storage of documentation, there was not a set of internal controls to ensure that the d...

Summary Description: During the summer the Campus Testing Coordinator (Instructional Coach) for the campus resigned. Although the testing coordinators received testing security training that included the required storage of documentation, there was not a set of internal controls to ensure that the documentation would be secured for the district. Points of Contact: ? Superintendent, Dr. Mechiel Rozas, mechiel.rozas@legacytraditional.org ? District STAAR Testing Coordinator, Valarie Walker, valarie.walker@legacytraditional.org ? Campus STAAR Campus Coordinator 2002-2023: Kehinde Stevenson, Evonne Murillo, Kim Wood, Molly Stumpo Resources Requirements: ? Campus Testing Coordinators have trained each semester using slides prepared by TEA with an overview of documentations requirements and storage. ? Testing Security training for Campus Testing Coordinators using the Learning Management System (LMS) in the Testing Information Distribution Engine (T.I.D.E.) Planned Milestones: ? Fall Campus Testing Coordinator Training (October 27, 2022) ? Training and signed documentation to verify understanding of the security requirements for the year and the steps to ensure securing protocols are followed if there is an early departure from duties. ? Campus Testing Coordinators meet with the District Testing Coordinator monthly to review expectations and confirm compliance. This information is shared with the district Superintendent on the first Monday in each month. ? Spring Campus Testing Coordinator Training (January 11, 2023) ? Training and signed documentation to verify understanding of the security requirements for the year and the steps to ensure securing protocols are followed if there is an early departure from duties. ? Original copies of documents submitted to the District Testing Coordinator at the end of each testing session and copies filed for the campus and maintained at the campus level (December 16, 2022 EOC; April 3, 2023 TELPAS; May 15, 2023 Spring STAAR and EOC; June 30, 2023 Summer EOC). Scheduled Completion Date: The campus Testing Coordinator will secure the Campus Principal signage page completed with final submission to the District Testing Coordinator along with Principal oaths by May 15, 2023 for elementary campuses and June 30,2023 for the high school campus. Change in Procedure: The District Testing Coordinator has enhanced the training for testing procedures and systems of accountability have been created. Campus Testing Coordinator training now includes testing security responsibilities if there is a departure from the position or the district. The district will continue to train Campus Testing Coordinators twice a year, but the internal controls now include the collection of original documents on specific dates at the end of each testing session, rather than at the end of the school year, along with monthly checks for compliance. The Principal of each campus must review the testing binder and secure storage of materials after completing the signage document in the testing binder and ensure submission of the testing binder to the District Testing Coordinator by the scheduled completion dates.

View Audit 16336

Finding 12201 (2022-002)

Material Weakness 2022

Lyon County School District

NV

Questioned Costs Cash Management Material Weakness

Views of Responsible Officials and Planned Correction Action: The Grants and Business Departments have worked together to create a process with appropriate checks and balances regarding moving expenses across individual grants and major funds. This process will consist of multiple levels of approval...

Views of Responsible Officials and Planned Correction Action: The Grants and Business Departments have worked together to create a process with appropriate checks and balances regarding moving expenses across individual grants and major funds. This process will consist of multiple levels of approval and specific documentation. Any entries will be processed in a timely manner and all expenditure reports will be checked for errors monthly. This process will ensure that expenditure reports are accurate at the time they are submitted for reimbursement.

View Audit 16323 Questioned Costs: $1

Finding 12198 (2022-003)

Significant Deficiency 2022

Lyon County School District

NV

Cash Management

Views of Responsible Officials and Planned Correction Action: The Grants Department was approved by the Nevada Department of Education to submit RFRs on a quarterly basis in FY23. The Grants Department has followed this approval and submitted all requests by the 15th day of the month following the q...

Views of Responsible Officials and Planned Correction Action: The Grants Department was approved by the Nevada Department of Education to submit RFRs on a quarterly basis in FY23. The Grants Department has followed this approval and submitted all requests by the 15th day of the month following the quarter-end.

View Audit 16323

Finding 12197 (2022-001)

Material Weakness 2022

Forrest City School District

AR

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

Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which i...

Contact Person(s) Responsible for Corrective Action: Dr. Tiffany Hardrick, Superintendent and Sharon Wilson, Federal Coordinator Corrective Action Planned: All services prepaid for professional development were rendered and properly documented, i.e participant sign in sheets and agendas which is required as part of the districts control procedures to ensure that services paid for are in fact received . It should be noted that the district prepaid for services based on verbal and email guidance of the Public-School Program Manager from DESE public school accountability department. The purpose of prepayment was to avoid returning funds as advised. (Email Documentation can be provided). In addition, Solution Tree, a state approved partner, sent an email as recently as April 3, 2023 encouraging districts to "Pre-pay years of PD with federal funds". (Documentation can be provided). However, the district will implement procedures to review payments to vendors in the future to ensure that services have been rendered prior to payment. Anticipated Completion Date: The corrective actions are anticipated to be complete and in place immediately after the completion date of this audit.

View Audit 16316 Questioned Costs: $1

Finding 12195 (2022-002)

Significant Deficiency 2022

Ensign College

UT

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023...

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-002 ? Pell Grant Notification Letters Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.063 Title: Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan This issue is a result of no manual or system controls in place to prevent disbursement of financial aid to a student?s account if a student?s federal financial aid award notification was not yet communicated. This issue was corrected as soon as it was identified by changing our procedures to require Pell notification letters be sent as soon as funds are awarded and before funds are disbursed to a student?s account. As an additional precaution, Pell notification letters will be added to the nightly batch process in PeopleSoft to ensure letters are sent timely. Financial aid staff will also receive additional training in this area. Timing Procedures will be changed in May 2023 by Riley Niemand, Manager of Financial Aid, to require Pell notification letters be sent as soon as funds are awarded and prior to funds being disbursed to a student?s account. During May 2023, Riley Niemand will also provide additional training to financial aid staff in this area. Additionally, Riley Niemand started working with a consultant to add Pell notification letters to the daily batch process. This work is expected to be complete by June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 16301

Finding 12194 (2022-001)

Significant Deficiency 2022

Ensign College

UT

Student Financial Aid Eligibility Significant Deficiency

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Pr...

Management Views and Corrective Action Plan Year Ending December 31, 2022 Finding 2022-001 ? Enrollment Reporting Grantor: U.S. Department of Education Program: Student Financial Assistance Cluster Assistance Listing #: 84.268, 84.063 Title: Federal Direct Student Loan Program, Federal Pell Grant Program Award Years: 7/2021 ? 6/2023 Management agrees with the finding and proposes the following Corrective Action Plan: Corrective Action Plan The prior year corrective action plans were successful in addressing the issues identified in previous audits in enrollment reporting. These additional steps will be taken to address the new issues found during the 2022 audit within enrollment reporting, which resulted in a repeat finding of 2021-001. Grayson Layton, Registrar, will review the College?s policies and procedures surrounding student enrollment and enrollment reporting, starting in May 2023 specifically as it relates to students that have withdrawn that are expected to return in the subsequent semester but fail to reenroll. Any changes in the College?s policies and procedures will be appropriately documented and communicated to the individuals involved in updating student enrollment information in the system. Additionally, Enrollment Services will work with a PeopleSoft consultant and technical staff to customize our Student Information System to allow for the correct reporting of student status to the National Student Clearinghouse (NSC). Technical staff and a consultant will be engaged to perform an evaluation of all systems and practices related to enrollment reporting. The Enrollment Services and Financial Aid and Scholarships Offices will use various NSC and National Student Loan Data System (NSLDS) error reports to ensure student enrollment information, including program level information, is reported in an accurate and timely manner. Timing Grayson Layton, Registrar, will work with consultants and technical staff starting in May 2023 to begin making necessary adjustments to the Student Information System to allow for accurate reporting of student enrollment information and to evaluate systems and practices related to enrollment reporting. They will meet monthly throughout the year to monitor their progress with an expected completion in December 2023. Grayson and Riley Niemand, Manager of Financial Aid, will coordinate the use of NSC and NSLDS error reports to identify students with reporting errors. This process will be complete in June 2023. Sincerely, S.Christopher Reitz Director of Financial Services and Controller creitz@ensign.edu 801-524-8109

View Audit 16301

Finding 12193 (2022-002)

Material Weakness 2022

City of Dunsmuir

CA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding: 2022-002 Agency: City of Dunsmuir Responsible person name/title: Blake Michaelsen, Finance Director Anticipated completion date: 06/30/2024 Agency?s response: Concur Corrective action plan: The City?s Finance Director will submit the written policies and procedures for all 12 com...

Finding: 2022-002 Agency: City of Dunsmuir Responsible person name/title: Blake Michaelsen, Finance Director Anticipated completion date: 06/30/2024 Agency?s response: Concur Corrective action plan: The City?s Finance Director will submit the written policies and procedures for all 12 compliance requirements found in the Uniform Guidance to City Council for approval and codification. The policies and procedures will be distributed to City staff and staff will be trained on the new policies and procedures.

View Audit 16299 Questioned Costs: $1

Finding 12180 (2022-005)

Material Weakness 2022

Rural Resources Community Action

WA

Reporting HUD Housing Programs

Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization CFO understands the function and necessity of preparing a complete and accurate SEFA. The organization will secure the Grants Management module to use wit...

Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization CFO understands the function and necessity of preparing a complete and accurate SEFA. The organization will secure the Grants Management module to use with the accounting software to enhance the ability to efficiently generate the SEFA in a timely manner for the annual audit. The CFO will be reviewing financial records to make sure all cash and noncash federal grants are included on the SEFA.

View Audit 16294

Finding 12179 (2022-004)

Material Weakness 2022

Rural Resources Community Action

WA

HUD Housing Programs Allowable Costs / Cost Principles

Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization management and Board of Di...

Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Organization management and Board of Directors understand the requirement and importance of submitting audited financial statements to the Federal Audit Clearinghouse in a timely matter. This will be monitored closely by the Board of Directors and management of the Organization for future audits to make sure that the audits are submitted timely.

View Audit 16294

Finding 12178 (2022-003)

Material Weakness 2022

Rural Resources Community Action

WA

HUD Housing Programs Cash Management Reporting

Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Chief Financial Officer (CFO) understa...

Management?s Response to 2022 Audited Financial Statements Findings and Corrective Action Plan: Rural Resources Community Action agrees with the findings reported and has identified corrective action to rectify the findings. The Chief Financial Officer (CFO) understands the importance of recording all revenue and deferred revenue to ensure accurate financial accounting and reporting. The Organization has acquired an accounts receivable module for their accounting software to record accounts receivable monthly. The CFO will be reviewing financial records to make sure all revenue and elimination of intercompany transactions are recorded.

View Audit 16294

Finding 12175 (2022-002)

Significant Deficiency 2022

Refugee Empowerment Center

NE

Allowable Costs / Cost Principles Cash Management HUD Housing Programs

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable complet...

Corrective Action Plan: The organization is implementing new software for tracking client expense, which has functionality to import copies of credit card receipts and check requests into each client?s record. We have emphasized to case managers the importance of keeping receipts. Reasonable completion date: June 1, 2023 Responsible Party: Tanya DeWolf, Director of Refugee Services

View Audit 16282

Finding 12174 (2022-001)

Material Weakness 2022

Refugee Empowerment Center

NE

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.431

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumente...

Corrective Action Plan: The organization has implemented a new payroll system, which includes time tracking. It has also changed its policy to pay overtime rather than accruing comp-time, as well as an implementing an unlimited PTO policy. These changes will eliminate charging grants for undocumented accrued time. Reasonable completion date: October 1, 2022 Responsible Party: Rick Rummel, Director of Finance & Administration

View Audit 16282 Questioned Costs: $1

Finding 12173 (2022-001)

Material Weakness 2022

Sunnycrest Village Project LLC

SD

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.327

Finding 2022-001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance Rental Housing Federal Financial Assistance Listing #14.134 Procurement, Suspension, and Debarment Finding Summary: The Project does not have a written procurement policy which co...

Finding 2022-001 Federal Agency Name: U.S. Department of Housing and Urban Development Program Name: Mortgage Insurance Rental Housing Federal Financial Assistance Listing #14.134 Procurement, Suspension, and Debarment Finding Summary: The Project does not have a written procurement policy which conforms to Uniform Guidance as outlined in 2CFR 200.317 through 200.327. During the year, management entered into transactions over the micropurchase threshold with eight vendors. Documentation was unable to be provided to support procurement compliance for seven vendors. In addition, there was one vendor with expenditures in excess of $25,000 and the Project did not verify the vendor against the central contractor registry prior to entering into the transaction or on a periodic basis to ensure that the vendor was not suspended or debarred. Responsible Individuals: Sue Lund, Administrator Corrective Action Plan: The Project is drafting a written procurement policy which conforms to Uniform Guidance as outlined above. In addition, for expenditures in excess of $25,000, the Project will verify the vendor against the central contractor registry prior to entering into the transaction or on a periodic basis to ensure that the vendor was not suspended or debarred. Anticipated Completion Date: July 2023

View Audit 16278

Finding 12169 (2022-001)

None 2022

Frankenmuth School District

MI

Cash Management School Nutrition Programs Internal Control / Segregation of Duties

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Se...

Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters noted below, and have described our planned actions as a result. 2022-001 - Program Income - Food Service Fund Balance Management Assessment - We concur with the audit assessment regarding this matter. Planned Corrective Action - The District is aware of the USDA fund balance requirements. The District operated under the Seamless Summer Option during fiscal year 2021-22 which allowed all of our students to eat both breakfast and lunch for free. The District received a large amount of federal funding which in turn resulted in more fund balance than allowed by USDA at 6/30/2022 ($5,466). The Food Service Director and Business Manager are in the process of creating a spenddown plan to be submitted to MDE which will move fund balance within an allowable range. Responsible Party - Business Manager Date of Planned Corrective Action - June 2023

View Audit 16273

Finding 12166 (2022-001)

Significant Deficiency 2022

Marana Health Center, INC

AZ

Significant Deficiency Internal Control / Segregation of Duties

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. ...

Marana Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit Period: July 1, 2021 - June 30, 2022 Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 1 of 2 I. PURPOSE: The Sliding Fee Schedule (SFS) Patient Demographic Changes process was created to ensure any patient who is certified on MHC Healthcare's (MHC) SFS and has changes on their Patient Profile (Profile) to their Family Size and/or Income are referred to the Outreach Department (OR) and that these changes are only made by an OR employee or the OR Manager. II. PROCESSES: A. Front Office (FO) staff print Profiles from the Electronic Health Record (EHR) for all patient appointments, which allows patients to make required changes to their demographics on file. This includes Family Size and/or Income. When a patient on MHC's SFS notifies FO of changes to the aforementioned demographics, the patient must be referred to the MHC OR Department for further review. Only OR staff may make these demographic changes in the EHR for SFS Patients. Ill. PROCEDURES: A. FO staff will print a Profile for all patient appointments. 1. FO will ensure all patients review the Profile for required changes to their demographics in the EHR system. a. If the patient is on the SFS and notates any changes required on the Profile to be made to their Family Size and/or Income, the FO will: 1) Immediately notify the health center's assigned OR employee that a patient in the office for an appointment has required changes to these demographics. a) Notification can be made via telephone or a Teams message. b) If the site does not have an assigned OR employee, notification will be made to the OR Manager. 2) The OR employee will respond to FO: a) The patient is placed on the OR schedule for an immediate appointment while the patient is in the health center and available, either prior to or after the clinical visit, depending on allowable time. b) An appointment will be scheduled while the patient is in the health center for a later date to review changes and the possible affect these changes may have on the patient's SFS certification and/or SFS tier. c) The patient is contacted via telephone by the OR employee to schedule an appointment to review the possible changes to the patient's SFS certification and/or SFS tier. d) When scheduling the appointment, the patient may schedule it at the Health Center or choose to have this appointment via telehealth. 3) Only OR employees may change the Family Size and/or Income demographics in the EHR for SFS patients. a) FO will make all necessary demographic changes in the EHR, excluding Family Size and/or Income. b. FO will scan the Profile into the EHR and forward a copy to the appropriate OR employee. 2. The OR Manager will ensure that FO staff have a current list of OR employees, along with appropriate contact information and location. Category: GENERAL MARANA HEALTH CENTER, INC. AD-2-010 Procedure: Sliding Fee Schedule Patient Demographic Changes Page 2 of 2 3. The OR Manager will immediately communicate any deviations to this policy and procedure to the assigned Associate Director of Integrated Operations (ADIO) when noted. IV. REFERENCES: Sliding Fee Schedule V. ATTACHMENTS: None Approved: Original Approval: 09/2022 9/28/2022 Date 9/28/2022 Date Reviewed/Revised: Responsible Party: Director, Integrated Operations If the Department of Health and Human Services has questions regarding this plan, please call Tamie Olson, CFO at (520) 784-8655.

View Audit 16269

Finding 12159 (2022-001)

Significant Deficiency 2022

Westfield Washington Schools

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.212 § 200.318

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action; Brian Tomamichel, Chief Financial Officer Contact Phone Number: 317-867-8013 ...

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action; Brian Tomamichel, Chief Financial Officer Contact Phone Number: 317-867-8013 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Westfield Washington Schools will be hiring a Director of Food Service to oversee our current food service management company. With this hire the district will ensure that this individual is routinely trained on procurement, contract approval, and any other necessary items to ensure that all Federal Uniform Guidance requirements such as suspension and debarment checks are performed prior to awarding contract. Anticipated Completion Date: June 2023

View Audit 16268

Finding 12158 (2022-001)

Material Weakness 2022

Portage County

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

Portage County will verify that a vendor is not suspended or debarred by checking the SAM exclusions, prior to contracting with any vendor that will be paid $25,000 or more with federal funds. A time stamped copy of the results of the SAM exclusions search will be saved in a vendor file.

View Audit 16244

Finding 12157 (2022-001)

None 2022

Osprey Wilds Environmental Learning Center

MN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.302 § 200.305

Contact Person Jolene Palme, Finance Manager Corrective Action Plan We are in the process of updating the Center?s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2023

View Audit 16241

Finding 12154 (2022-001)

None 2022

Loretto O'Brien Road 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 $1,400 deposit into the reserve for replacements when cash flow was sufficient. Action Taken: O?Brien Road Senior Apartme...

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 $1,400 deposit into the reserve for replacements when cash flow was sufficient. Action Taken: O?Brien Road Senior Apartments made the required payment in April 2022. Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO, (315) 424-1821. Completion Date: April 2022

View Audit 16240

Finding 12153 (2022-001)

None 2022

Eagle County School District Re50j

CO

Subrecipient Monitoring § 200.332 § 200.501

Reference Number: 2022-001 Assistance Listing Number: 84.425 Federal Program Title: Education Stabilization Fund Awarding Agency / Pass-Through Entity: U.S. Department of Education, Colorado Department of Education Compliance Requirement: Subrecipient Monitoring Criteria: None for ECSD Correct...

Reference Number: 2022-001 Assistance Listing Number: 84.425 Federal Program Title: Education Stabilization Fund Awarding Agency / Pass-Through Entity: U.S. Department of Education, Colorado Department of Education Compliance Requirement: Subrecipient Monitoring Criteria: None for ECSD Corrective Action: The District agrees with the finding and has adopted Policy Regulations: DD-R, Project Partnerships, Sub-Award Grants, Sub-Contracts Pursuant to Grants, and Third-Party Grants Involving District Personnel, Programs or Facilities and; DD-R2, Grants to District Personnel Personnel Responsible: Sandra Farrell, COO and Chelsey Gerard, Director of Finance Completion Date: October 31, 2022

View Audit 16239

Finding 12150 (2022-001)

Significant Deficiency 2022

Richland Medical Center, Inc. D/b/a Central Ozarks Medical Center

MO

Subrecipient Monitoring Eligibility HUD Housing Programs

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 0...

CORRECTIVE ACTION PLAN May 30, 2023 United States Department of Health and Human Services Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center respectfully submits the following corrective action plan for the year ended November 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: November 30,2022 The findings from the November 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCIES Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID - 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), and Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 2022-001 Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken In May 2022 COMC hired a Sliding Fee Coordinator. This position reviews all new slide fee applications to ensure all required documentation is present and that the correct slide scale has been applied. This position also reviews current slide applications for patients that are sacheduled for upcoming appointments to ensure paperwork is current or if paperwork is outdated a new application is received. This position also monitors and trains staff on the slide fee process. The finding from this year was prior to the position being filled in 2022. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sabrina McAfee, CFO at (573) 836-7079. Sincerely yours, Sabrina McAfee Chief Financial Officer

View Audit 16226

Finding 12149 (2022-001)

Significant Deficiency 2022

Nutrition, INC

IN

Internal Control / Segregation of Duties

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties proces...

Finding 2022-001 ? Financial Statement and Federal Awards Statement of Condition: Nutrition was not segregating duties of accounting and administrative responsibilities for internal control purposes. Status: Coming out of the pandemic impacted the ability to complete the segregation of duties process, due to the lack of staff. As a result, Nutrition is working to develop the processes that will help to implement the procedures that will segregate duties and will continue working with team members to implement processes to segregate duties moving forward. At this time, the development is on-going and will take place when the business growth warrants and supports such an action. Presently, adding additional staff to provide another layer of preparation, review, and monitoring would outweigh the costs.

View Audit 16224

Finding 12148 (2022-001)

None 2022

Healthy Start

IL

Cash Management

Corrective Action Plan Fiscal Year September 30, 2022 2022-01 Condition:In a sample of 40 centers reimbursement requests 25 of 40 centers, which represents 40 of 112 centers filing claims in fiscal year 2022 with the Sponsor, the period between the last monitor visit of fiscal year 2021 and the fir...

Corrective Action Plan Fiscal Year September 30, 2022 2022-01 Condition:In a sample of 40 centers reimbursement requests 25 of 40 centers, which represents 40 of 112 centers filing claims in fiscal year 2022 with the Sponsor, the period between the last monitor visit of fiscal year 2021 and the first monitor visit of fiscal year 2022 exceed six months. Management response:Management had a decrease in staff due to Covid and had fewer monitors available to complete the monitor visits. Corrective action taken: Management has increased the staff to complete the monitor visits within the required time to avoid a six (6) month lapse between monitor visits of sites. In addition Management has created a software program of the schedule of all Centers to notify Management of the days left prior to a six (6) month lapse. The software will give an alert of the number of days remaining for each Center before it reaches the six (6) months and allow Management to facilitate the timely scheduling of monitor visits.

View Audit 16217

Finding 12137 (2022-002)

Significant Deficiency 2022

Texas Biomedical Research Institute

TX

Cash Management Subrecipient Monitoring § 200.303 § 200.305

Finding 2022-002 ? Cash Management ? Pass-Through Entities Condition: Texas Biomed did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. Texas Biomed paid 2 of 23 sub...

Finding 2022-002 ? Cash Management ? Pass-Through Entities Condition: Texas Biomed did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. Texas Biomed paid 2 of 23 subrecipients after 30 days of receipt of the request for reimbursement from the subrecipient, resulting in noncompliance with 2 CFR 200.305(b)(3). Corrective Action Plan: Texas Biomed will implement a more effective operating procedure for subrecipient invoice approval and timely payment that will include timeline expectations for the initial approval request to the applicable principal investigator upon receipt of invoices from the subrecipient, timeline for following-up with the principal investigator on approval requests, timeline and direction for seeking proxy approval if the principal investigator is unavailable or unable to provide a timely response, and timeline for entering the subrecipient invoice in Texas Biomed financial systems facilitating payment upon approval. Responsible Parties: Eduardo Meza, Director, Sponsored Programs Administration Completion Date: June 1, 2023

View Audit 16215

Corrective Action Plans

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