Corrective Action Plans

Finding 35952 (2022-004)

Significant Deficiency 2022

Southern California University of Health Sciences

CA

Student Financial Aid Reporting Significant Deficiency

Both the Financial Aid team and Student Accounts team have developed a weekly disbursement and posting schedule. A cut off time for processing will be implemented to ensure both dates are aligned and to accommodate any file response import delays.

View Audit 32937

Finding 35951 (2022-002)

Significant Deficiency 2022

Southern California University of Health Sciences

CA

Student Financial Aid Reporting Significant Deficiency

We recommend the University review its reporting procedures to ensure that roster file submissions are reported timely to NSLDS as required by regulations.

View Audit 32937

Finding 35950 (2022-001)

Significant Deficiency 2022

Southern California University of Health Sciences

CA

Student Financial Aid Reporting Significant Deficiency

The University contracted with National Student Clearinghouse (NSC). In the prior year, we identified a data exchange issue between our institution and NSC. We have now resolved that issue.

View Audit 32937

Finding 35949 (2022-003)

Significant Deficiency 2022

Spectrum River Vale Apartments, INC

NJ

HUD Housing Programs

Finding: 2022-003 Finding Description: The Organization had excess funds over $250 remaining in the residual receipts account which have not been remitted to HUD upon PRAC termination. Corrective Action Taken or Planned: Residual receipts that are due to HUD will be made on or before April 30, 2023....

Finding: 2022-003 Finding Description: The Organization had excess funds over $250 remaining in the residual receipts account which have not been remitted to HUD upon PRAC termination. Corrective Action Taken or Planned: Residual receipts that are due to HUD will be made on or before April 30, 2023. Contact Person Responsible for Corrective Action: Danny Rosario, CFO Anticipated Completion Date: April 30, 2023

View Audit 31779

Finding 35948 (2022-002)

Significant Deficiency 2022

Spectrum River Vale Apartments, INC

NJ

HUD Housing Programs

Finding: 2022-002 Finding Description: The Organization made a transfer out of the replacement reserve account, totaling $7,940, without receiving proper approval from HUD. Corrective Action Taken or Planned: A transfer of $7,940 will be made to the replacement reserve account on or before April 30,...

Finding: 2022-002 Finding Description: The Organization made a transfer out of the replacement reserve account, totaling $7,940, without receiving proper approval from HUD. Corrective Action Taken or Planned: A transfer of $7,940 will be made to the replacement reserve account on or before April 30, 2023.In addition, no transfers will be made out of the replacement reserve account without written HUD approval. Any transfers made out of the replacement reserve account must be approved by the CFO after receiving HUD approval. Contact Person Responsible for Corrective Action: Danny Rosario, CFO Anticipated Completion Date: April 30, 2023

View Audit 31779

Finding 35947 (2022-001)

Material Weakness 2022

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring

Management will continue to monitor and review auditor draft financial statement.

View Audit 24789

Finding 35946 (2022-002)

Significant Deficiency 2022

Rva Financial Federal Credit Union

VA

Reporting Significant Deficiency Internal Control / Segregation of Duties

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF THE TREASURY 2022-002 COVID-19 ? Community Development Financial Institutions Rapid Response Program (CDFI RRP) ? Assistance Listing No. 21.024 Recommendation: We recommend management monitor reporting requirements and implement internal control p...

FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF THE TREASURY 2022-002 COVID-19 ? Community Development Financial Institutions Rapid Response Program (CDFI RRP) ? Assistance Listing No. 21.024 Recommendation: We recommend management monitor reporting requirements and implement internal control procedures to ensure reporting due dates are followed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will monitor the due dates to ensure there are no late filings. If the Department of the Treasury has questions regarding this plan, please call Cindy Lindsey at 804-359- 8754, ext. 3172.

View Audit 28030

Finding 35939 (2022-003)

Material Weakness 2022

Johnson County, Iowa

IA

Subrecipient Monitoring § 200.303 § 200.331 § 200.333

Finding: 2022-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Finding Summary: The County did not formally communicate the required informatio...

Finding: 2022-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring Finding Summary: The County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: Johnson County disagrees with the underlying premises of this finding. This finding is due in part to the fiscal agent agreement with Iowa Workforce Development (?IWD?) which does not state that subrecipient monitoring has to be done. Recently, IWD received a finding from the Department of Labor stating that the template fiscal agent agreements imposed upon fiscal agents by IWD improperly placed liability of disallowed costs onto the fiscal agents. According to DOL, IWD?s form of fiscal agent contract was incorrect, i.e., the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement, and no longer continue to be the fiscal agent as of June 30, 2023. Anticipated Completion Date: Ongoing

View Audit 27011

Finding 35938 (2022-002)

Material Weakness 2022

Johnson County, Iowa

IA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303 § 200.403

Finding: 2022-002 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Activities Allowed or Unallowed Finding Summary: The County?s expenditures identified as eligible and cl...

Finding: 2022-002 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Activities Allowed or Unallowed Finding Summary: The County?s expenditures identified as eligible and claimed under the WIOA Cluster program were disallowed by the United States Department of Labor due the lack of appropriate documentation justifying specific costs charged to the program related to one vendor ? Garcia Professional Services, LLC. Also, the contract entered into with Garcia Professional Solutions, LLC. did not adequately address the required contract terms as follows: 1. Total dollar value of the contract to justify procurement method utilized. 2. Terms for payment to ensure payments are only made for verified services received and adequately documented. 3. Contract provisions stipulated in Appendix II to Part 200 of the Uniform Guidance, including Equal Employment Opportunity, Rights to Inventions Made Under a Contract or Agreement, Debarment and Suspension, and Byrd Anti-Lobbying Amendment. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: Johnson County disagrees with the underlying premises of this finding. The expenditures referred to above were expenditures of the East Central Iowa Workforce Development Board (ECIWDB) and not direct expenses of the County. The ECIWDB contracted with Johnson County to provide fiscal agent services. The ECIWDB then entered into a contract with Garcia Professional Solutions, LLC (?GPS?) to provide administrative support services for the Board. Iowa Workforce Development did not provide adequate guidance to ECIWDB as to the DOL-required terms and the terms of that services contract between ECIWDB and GPS did not contain any standards of documentation which DOL later claimed applied to said contract. The County had no input into the contract between the ECIWDB and GPS, nor was the County a party to said contract. Any alleged deficiencies within that contract between the ECIWDB and GPS are solely the responsibility of the ECIWDB Board and/or Iowa Workforce Development. In our fiscal agent role, the County was obliged to honor payment requests submitted to the Board; in that regard we had to make payments to GPS provided those payment requests were invoiced to ECIWDB consistent with the ECIWDB-GPS contract, which they were. Anticipated Completion Date: Ongoing

View Audit 27011 Questioned Costs: $1

Finding 35937 (2022-001)

None 2022

Town of Athol

MA

Questioned Costs Cash Management Eligibility

Finding 2022-001 Condition: The Town charged the same invoice twice to the federal award. Corrective Action Planned: The Town has contacted the Commonwealth of Massachusetts Executive Office for Administration and Finance regarding the duplicate invoice. We are awaiting a response as to how to...

Finding 2022-001 Condition: The Town charged the same invoice twice to the federal award. Corrective Action Planned: The Town has contacted the Commonwealth of Massachusetts Executive Office for Administration and Finance regarding the duplicate invoice. We are awaiting a response as to how to resolve the overpayment. Anticipated Completion Date: June 30, 2023 Contact: Amy Craven, Town Accountant

View Audit 26180 Questioned Costs: $1

Finding 35935 (2022-004)

Significant Deficiency 2022

Stark County Housing Authority

ND

HUD Housing Programs Eligibility Significant Deficiency

2022-001 Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Housing Authority has reorganized roles and responsibilities to ensure that all reporting is accurate and all tenant files are correctly maintained. The Compliance Officer and Director of Finance have received trainin...

2022-001 Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Housing Authority has reorganized roles and responsibilities to ensure that all reporting is accurate and all tenant files are correctly maintained. The Compliance Officer and Director of Finance have received training and certification in Rural Development and Multifamily Compliance and handle all tenant files and uploads. Planned Completion Date for CAP Changes were implemented immediately. 2022-002 Contact Person Derek Johnson, Managing Agent Correction Action Plan No action planned on the finding. The Authority and board feel that the additional costs to the Authority would not be significantly beneficial. The Authority does mitigate this situation through the review of the draft financial statements and accompanying notes to the financial statements. Planned Completion Date for CAP None. See above. 2022-003 Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority?s management and Board of Commissioners will review proposed audit entries and approve them. Any common adjustments, such as those identified in the current year, not likely to be recurring, will be reviewed and approved by appropriate Authority personnel. The Director of Finance drafts the journal entries, which are reviewed and approved by the Executive Director. Planned Completion Date for CAP Immediately 2022-004 Contact Person Derek Johnson, Managing Agent Correction Action Plan The Authority has hired a Deputy Director who completes quality control audits on all tenant files periodically. The Deputy Director holds monthly meetings with all eligibility staff workers to ensure compliance with policies and procedures. Planned Completion Date for CAP Immediately

View Audit 25514

Finding 35923 (2022-001)

None 2022

Springfield College

MA

Student Financial Aid Reporting

Springfield College June 30, 2022 Finding 2022-001 Fiscal Operations Report and Application to Participate Corrective Action Planned The Corrective Action Plan (CAP) has three components. First, the Director of Financial Aid will conduct additional training with the staff from the processing unit. T...

Springfield College June 30, 2022 Finding 2022-001 Fiscal Operations Report and Application to Participate Corrective Action Planned The Corrective Action Plan (CAP) has three components. First, the Director of Financial Aid will conduct additional training with the staff from the processing unit. The training will review the field in the financial aid management system that must be updated and the importance to the FISAP. This training is scheduled for the week of November 14, 2022. Second, we implemented a work-flow task in our financial aid management system to notify the financial aid counselor to review the academic grade level flag for each term the student is enrolled. This component was implemented on November 3, 2022. Third, prior to submission of the FISAP the Director will develop a report to detect academic grade level inaccuracies. The anticipated completion date for this component is September 2023. Person Responsible for Corrective Action Plan Troy A. W. Davis Anticipated Completion Date September 2023

View Audit 25057

Finding 35922 (2022-002)

Significant Deficiency 2022

Spring Hill College

AL

Reporting

Condition: There was no quarterly reporting for the fourth quarter of 2021 for the Institutional Portion of the HEERF III grant. Criteria: Institutions must complete and post on their websites an institutional reporting form. This form includes reporting categories on mental health spending, HEERF ...

Condition: There was no quarterly reporting for the fourth quarter of 2021 for the Institutional Portion of the HEERF III grant. Criteria: Institutions must complete and post on their websites an institutional reporting form. This form includes reporting categories on mental health spending, HEERF (a)(2) construction flexibilities, and lost revenue. This form must be conspicuously posted on the institutions? website no later than 10 days after the calendar quarter (January 10, April 10, July 10, and October 10) as long as the institution?s HEERF grant is active. Cause: The College did not prepare or post the quarterly report for the Institutional Portion of the HEERF III grant for the fourth quarter of 2021. Context: During the compliance audit testing of ALN 84.425F, it was determined that the College did not fully adhere to the quarterly reporting compliance requirement for the Institutional Portion of the HEERF III grant. Recommendation: We recommend compliance with all reporting requirements for the HEERF III grant. View of Responsible Officials and Planned Corrective Action: The report indicating institutional dollars spent for fourth quarter of 2021 has been posted to the College's website as of March 29, 2023. Going forward all reports will be submitted and posted in a timely manner.

View Audit 25502

Finding 35920 (2022-001)

Significant Deficiency 2022

Spring Hill College

AL

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Condition: There was lack of documentation related to disbursement notices and exit counseling for nine out of thirty-four students tested. Criteria: According to ?668.165, before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the a...

Condition: There was lack of documentation related to disbursement notices and exit counseling for nine out of thirty-four students tested. Criteria: According to ?668.165, before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. Additionally, according to ?682.604, a school must ensure that exit counseling is conducted with each loan borrower and graduate either in person, by audiovisual presentation, or by interactive electronic means. Cause: The College was unable to locate the documents for the students as a result of transitioning softwares. Effect: Certain documentation for disbursement notices and exit counseling was lost during the transition of the College's software. Context: During the compliance audit testing of ALN 84.268 and ALN 84.379, it was determined that documenation to confirm delivery of disbursement notices and performance of exit counseling could not be provided for certain students selected for testing. Recommendation: We recommend all required documentation be backed up to support compliance with certain requirements. View of Responsible Officials and Planned Corrective Action: The College is currently working with their IT department to make sure that all types of communication includes copying the financial aid department email to make sure the College has support for all communications to prevent this in the future.

View Audit 25502

Finding 35919 (2022-003)

None 2022

Legal Aid Society of Mid-New York, Inc.

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

2022-003: Payroll Timecard Completion. Contact Person Responsible for Corrective Action Plan: Paul J. Lupia, Executive Director. Corrective Action Plan: The Executive Director will reinforce the importance of the timely completion of timecards with all employees. Anticipated Completion Date of Corre...

2022-003: Payroll Timecard Completion. Contact Person Responsible for Corrective Action Plan: Paul J. Lupia, Executive Director. Corrective Action Plan: The Executive Director will reinforce the importance of the timely completion of timecards with all employees. Anticipated Completion Date of Corrective Action Plan: June 30, 2023.

View Audit 25144

Finding 35918 (2022-005)

Significant Deficiency 2022

Hawaii Pacific University

HI

Procurement, Suspension & Debarment

Views of Responsible Officials and Planned Corrective Action The HPU Office of Sponsored Projects will work collaboratively with the department to ensure that the required procedure for verification of Suspension and Debarment is consistently conducted and evidence of such procedure is maintained. ...

Views of Responsible Officials and Planned Corrective Action The HPU Office of Sponsored Projects will work collaboratively with the department to ensure that the required procedure for verification of Suspension and Debarment is consistently conducted and evidence of such procedure is maintained. The OSP Office will strengthen its policies and procedures so that the SAM screenshot for all covered transactions is complete and retained. The Principal Investigator should work collaboratively with the OSP to ensure that the documentation for suspension and debarment for vendors meeting this requirement is obtained and maintained. The Manager for Grants and Contracts will be sure to check the SAM.gov for suspension and debarment and will maintain the documentation. The Assistant VP of the Office of Sponsored Projects will review the documentation. Person Responsible: Principal Investigator, Assistant VP of Office of Sponsored Projects and Manager of Office of Sponsored Projects, Grant and Contracts Specialist. Targeted Correction Date: June 30, 2023.

View Audit 34010

Finding 35917 (2022-004)

Material Weakness 2022

Hawaii Pacific University

HI

Equipment & Real Property Management § 200.313

Views of Responsible Officials and Planned Corrective Action The HPU Fixed Asset Accountant, Federal Grant Project Investigator and Office of Sponsored Projects will work collaboratively to ensure that the physical inventory of all fixed assets which were acquired using federal funds are conducted ...

Views of Responsible Officials and Planned Corrective Action The HPU Fixed Asset Accountant, Federal Grant Project Investigator and Office of Sponsored Projects will work collaboratively to ensure that the physical inventory of all fixed assets which were acquired using federal funds are conducted and completed periodically. This physical inventory monitoring will be done at least, every two years. The team will work on getting all departments covered in the periodic inventory to confirm that the fixed asset listing is complete, updated and maintained. Person Responsible: Fixed Asset Accountant, Respective Project Investigator, Assistant VP of Office of Sponsored Projects and Manager of Office of Sponsored Projects. Targeted Correction Date: June 30, 2023.

View Audit 34010

Finding 35915 (2022-003)

Significant Deficiency 2022

Wellspace Health

CA

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

2022-003 Special Test and Provisions ? Sliding Fee Discounts Corrective Action Plan: WellSpace concurs with recommendations to strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, WellSpace will conduct monthly application audits. An audit of...

2022-003 Special Test and Provisions ? Sliding Fee Discounts Corrective Action Plan: WellSpace concurs with recommendations to strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, WellSpace will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross-verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. Furthermore, WellSpace will continue the practice of conducting skills assessments at the start of the year and once more in July. These assessments are crucial as they help pinpoint staff members who might benefit from refresher training. Moreover, a meeting has been scheduled to finalize the days and times for virtual sliding fee application training. This training, aimed at all staff who handle a sliding fee form, will be spread out over four weeks, with one session per week lasting an hour. Additionally, WellSpace will introduce a sliding fee training video to the new employee orientation. After completing their NextGen training, staff will receive this training video via email. Furthermore, this video will also be sent to all health center leadership to be utilized at the health center level. Estimated completion date: July 31, 2024 Contact person: Shannon Potter, Deputy Chief of Business Service

View Audit 37996 Questioned Costs: $1

Finding 35914 (2022-005)

Significant Deficiency 2022

Board of Education of the City of Peoria

IL

Questioned Costs Equipment & Real Property Management Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions: The District?s Fine Arts and Finance Departments will collaborate to ensure all program equipment and property purchases exceeding $500 involving federal monies are appropriately tracked.

View Audit 33950 Questioned Costs: $1

Finding 35913 (2022-003)

Significant Deficiency 2022

Board of Education of the City of Peoria

IL

Questioned Costs Internal Control / Segregation of Duties Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Management reviews and approves p-card transactions; however, no system documentation exists to provide evidence that this approval occurs. Consequently, the District has automated its p-card approval/expense authorization process in Sky...

Views of Responsible Officials and Planned Corrective Actions: Management reviews and approves p-card transactions; however, no system documentation exists to provide evidence that this approval occurs. Consequently, the District has automated its p-card approval/expense authorization process in Skyward. Regarding time and effort logs, management will work with the relevant department(s) to ensure this compliance finding is addressed.

View Audit 33950 Questioned Costs: $1

Finding 35912 (2022-004)

Significant Deficiency 2022

Board of Education of the City of Peoria

IL

Questioned Costs Internal Control / Segregation of Duties Significant Deficiency

Views of Responsible Officials and Planned Corrective Actions: Management reviews and approves p-card transactions; however, no system documentation exists to provide evidence that this approval occurs. Consequently, the District has automated its p-card approval/expense authorization process in Sky...

Views of Responsible Officials and Planned Corrective Actions: Management reviews and approves p-card transactions; however, no system documentation exists to provide evidence that this approval occurs. Consequently, the District has automated its p-card approval/expense authorization process in Skyward. Regarding time and effort logs, management will work with the relevant department(s) to ensure this compliance finding is addressed.

View Audit 33950 Questioned Costs: $1

Finding 35903 (2022-003)

Significant Deficiency 2022

Lyon College

AR

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

Finding 2022-003: Policies and Procedures Related to Packaging Student Financial Aid ? SFA Cluster (significant deficiency) Corrective Action: Lyon College has two employees in the Financial Aid office. We do have a process in place to review the packaging of new student aid (FTFT and TXFR), tho...

Finding 2022-003: Policies and Procedures Related to Packaging Student Financial Aid ? SFA Cluster (significant deficiency) Corrective Action: Lyon College has two employees in the Financial Aid office. We do have a process in place to review the packaging of new student aid (FTFT and TXFR), though it is very manual, and requires both FA employees to be involved (in order to separate duties). It is still not foolproof. Our current software will not prevent us from overpackaging subsidized loans in our manual packaging process, but we can run a report to check and see if the field marked `Awards to Report as Need-Based? is greater than the field marked `Original Need?. If any are found, we can make the necessary adjustment. In the packaging of returning students ? the larger group of students - we do not have a review process in place. We will review to see if we can find a practical way, with our current limited personnel, to implement a review process for returning student award packages. The overpackaged student was simply a human keystroke error. Sub (remaining need) was calculated to be $4,484 and we input $4,884, a transposition. This was a returning student who likely did not get reviewed, and we also failed to pick it up in the process described below, comparing original need to awards marked as need. Our current software will not prevent us from overpackaging subsidized loans in our manual packaging process, but we can run a report to check and see if the field marked `Awards to Report as Need-Based? is greater than the field marked `Original Need?. If any are found, we can make the necessary adjustment. The other student was underpackaged with subsidized loans. In this case, the student was packaged on 7/15 based off of the only FAFSA we had available at that time, received on 6/29. On that FAFSA, the student had an EFC of $28,180, and no need. Therefore, all loans ($7,500) were packaged as unsubsidized. A PLUS loan denial came in the next day and the additional $5,000 was also packaged as unsubsidized. On 8/4, a revised FAFSA came in showing an EFC of $5,119. No adjustment was made to reclassify part of the loans as subsidized based on the `need? shown on the revised FAFSA. The Financial Aid Office believes that running the comparison report mentioned above on a regular basis will help us to find over-packaged need-based loans that we either made a mistake on during our initial packaging process, or due to a revised FAFSA that created additional need. Proposed Completion Date: The FAO will begin running the `Original Need vs. Aid Packaged As Need? Report on a monthly basis, and most importantly, in August immediately before aid is originated and disbursed.

View Audit 38070

Finding 35902 (2022-002)

Significant Deficiency 2022

Lyon College

AR

Student Financial Aid Reporting Significant Deficiency

Finding 2022-002: Policies and Procedures Related to Withdrawals ? SFA Cluster (significant deficiency) Corrective Action: The ?Timely Reporting? issue resulted from a misunderstanding in the Registrar?s Office regarding the requirements of what had to be reported and by when. We have discussed t...

Finding 2022-002: Policies and Procedures Related to Withdrawals ? SFA Cluster (significant deficiency) Corrective Action: The ?Timely Reporting? issue resulted from a misunderstanding in the Registrar?s Office regarding the requirements of what had to be reported and by when. We have discussed this issue with that office?s personnel and established procedures designed to prevent it from happening in the future. The ?Funds Not Returned Timely? reflects continued improvements resulting from policies already established to enhance compliance with attendance reporting and tracking of those reports by the Registrar and Financial Aid Offices. The College will continue to reinforce compliance with the attendance monitoring and reporting policy, as well as refine procedures for active monitoring of those reports by these two offices. In particular, the process of evaluating whether students who are on the two-week absence report in any one class are in fact at risk of falling out of enrollment status overall. Proposed Completion Date: June 30, 2023

View Audit 38070

Finding 35901 (2022-002)

Significant Deficiency 2022

Atrium Health, Inc.

NC

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Finding 2022-002: Allowability (COVID-19 ? Provider Relief Fund) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pand...

Finding 2022-002: Allowability (COVID-19 ? Provider Relief Fund) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023. There are no additional PRF reporting periods required to be completed for Wilkes Regional Medical Center and Atrium Health management, when contacted, will provide HRSA auditors similar documentation to support the conclusion reached for these COVID-19 related expenses. Proposed Completion Date: Management will complete the corrective action plan upon request by HRSA.

View Audit 37993 Questioned Costs: $1

Finding 35900 (2022-001)

Significant Deficiency 2022

Atrium Health, Inc.

NC

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2022-001: Allowability (COVID-19 ? HRSA COVID-19 Uninsured Program) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria p...

Finding 2022-001: Allowability (COVID-19 ? HRSA COVID-19 Uninsured Program) Name of Contact Person: David Thomas, Group Vice President & Controller Corrective Action Plan: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022. Proposed Completion Date: Management completed the 2021 corrective action plan by the end of September 2022. All findings were prior to this date.

View Audit 37993

Corrective Action Plans

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