Corrective Action Plans

Finding 34609 (2022-011)

Material Weakness 2022

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Reporting has been built to notify responsible parties of the award periods of performance and highlight any issues for corrective action in accordance to previously filed FFATA reporting. In addition, FFATA reporting has been created in EOLWD?s DataMart application. Actions taken are as follows: ? Performed FFATA training ? Created accounts for employee access to FFATA ? Filed existing outstanding and new grant FFATA reports ? Used new reporting to notify responsible parties that a new grant/modification has arrived and requires a FFATA Subaward report filed ? Training for existing staff complete and new staff will be trained accordingly as part of their onboarding. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: June 30, 2023

View Audit 31118

Finding 34608 (2022-010)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17....

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Staffing: Two new Budget Analysts will begin working for EOLWD at the end of June in 2023. These analysts will provide additional capacity for filing 9130s for WIOA. Training: In March and April 2023, EOLWD provided training to new staff on the preparation, certification, and submission of 9130 reports. Staff beginning in June 2023 will be trained during the next 9130 reporting period. Automating Business Practices: EOLWD refined its automated 9130 reporting for the March 31, 2023, reporting period and is finalizing further refinements that will be implemented prior to the next quarterly reporting period. Standard Operating Procedures: EOLWD developed job aides for the preparation of 9130 reports with its new automated processes and is in the process of drafting new Standard Operating Procedures (SOP). These SOPs will be finalized and submitted to DOL by October 1, 2023, as outlined in the corrective action plan schedule provided to DOL. An updated version of this schedule is provided below. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: October 1, 2023

View Audit 31118

Finding 34607 (2022-001)

Significant Deficiency 2022

Legal Aid of North Carolina, Inc.

NC

Subrecipient Monitoring HUD Housing Programs

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor...

CORRECTIVE ACTION PLAN April 28, 2023 Legal Services Corporation Legal Aid of North Carolina, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Romeo, Wiggins & Company, LLP, 8210 Creedmoor Road, Suite 202, Raleigh, NC 27613 Audit Period: Year Ended December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2022-001: Case File Documentation/CFDA 09.634032 Recommendation: We recommend that management re-emphasize the importance of maintaining adequate documentation of retainer determination for all LSC eligible cases. Periodic reviews of case files should be performed to ensure compliance. Action Taken: The largest number of errors were discovered in one office, which office has a relatively new managing attorney. Legal Aid of North Carolina, Inc.?s Compliance Officer will provide compliance training targeted to this manager and her staff, emphasize compliance in new hire onboarding training, and train managers and supervisors promoted to new leadership roles. Additionally, all advocacy staff (attorneys and paralegals) will have mandatory annual refresher training on when and how to execute retainers. The training will also include a review of LSC Regulation 1611.9, Retainer Agreements. To strengthen the compliance process and assure requirements are met, Legal Aid of North Carolina, Inc. will perform semi-annual internal self-inspections to include retainer monitoring. We also plan to perform retainer monitoring of field offices that this audit and future self-inspections identify as missing required case documentation, including retainer agreements. Finally, our case management system will be evaluated for opportunities to more systematic alert case closing approvers or report on potential missing required documents. Legal Services Corporation Page Two If Legal Services Corporation has questions regarding this plan, please call Jim Strand, LANC CFO at 984-263-9609. Sincerely yours, Ashley Campbell Chief Executive Officer

View Audit 36954

Finding 34602 (2022-003)

Significant Deficiency 2022

Community Unit School District No. 3

IL

Subrecipient Monitoring Cash Management Reporting

United States Department of Education Education Stabilization Fund ? CFDA #84.425D/84.425U/84.425W Corrective Action Plan ? Noncompliance with Reporting Requirements Finding: 2022-003 Condition: The District has inadequate controls over reviewing and approving quarterly ?historical expenditure repor...

United States Department of Education Education Stabilization Fund ? CFDA #84.425D/84.425U/84.425W Corrective Action Plan ? Noncompliance with Reporting Requirements Finding: 2022-003 Condition: The District has inadequate controls over reviewing and approving quarterly ?historical expenditure reports? filed with the Illinois State Board of Education. Plan: The superintendent will review and approve quarterly ?historical expenditure reports? and supporting documentation on a regular basis prior to electronic submissions. Corresponding documents will be manually signed and dated to indicate approval. Anticipated Date of Completion: January 1, 2023 Management Response: The District intends to implement the recommendations in FY 2023. Name of Contact Person: Jessica Sisil, District Superintendent

View Audit 36244

Finding 34600 (2022-001)

Significant Deficiency 2022

University of Tulsa

OK

Questioned Costs Student Financial Aid Special Tests & Provisions

Corrective Action Plan The University of Tulsa Student Financial Services External Audit: Academic Year 21/22 During the spring 2022 semester, The University of Tulsa closed for a 5-day period due to inclement weather. The Return of Title IV (R2T4) calculations that were conducted adjusted total...

Corrective Action Plan The University of Tulsa Student Financial Services External Audit: Academic Year 21/22 During the spring 2022 semester, The University of Tulsa closed for a 5-day period due to inclement weather. The Return of Title IV (R2T4) calculations that were conducted adjusted total number of days in the semester; but did not adjust total days attended on the R2T4 calculations. The University of Tulsa reviewed all R2T4 calculations for spring 2022 with a withdraw date of February 2 or after. 11 recalculations were required, funds are being returned to the Department of Education. For future semesters, the formula for breaks will be hard coded into the COD R2T4 formula for all new breaks in the event of school closure during a semester to avoid missing either a reduction in the numerator or denominator. Name of the contact person responsible for corrective action: Vicki Hendrickson, Director, Student Financial Services

View Audit 35438 Questioned Costs: $1

Finding 34596 (2022-001)

Material Weakness 2022

Dawson County School District No. 20

NE

Internal Control / Segregation of Duties

The entity's Board continually evaluates the distribution of duties to employees and closely monitors all accounting functions.

View Audit 35996

Finding 34595 (2022-002)

Material Weakness 2022

Dawson County School District No. 20

NE

Questioned Costs

The entity's Board and management were not aware of the Davis-Bacon wage requirements relating to construction contracts paid with ESF Funds. An individual at the district will be in charge of ensuring Davis-Bacon requirements are met in the future for any projects that must comply.

View Audit 35996 Questioned Costs: $1

Finding 34592 (2022-001)

Significant Deficiency 2022

Kearney Public Schools District No. 07

NE

Internal Control / Segregation of Duties

The entity's Board continually evaluates the distribution of duties to employees and closely monitors all accounting functions. The School District has implemented controls within its accounting functions to mitigate the lack of segregation of duties but recognizez that this should still be a concer...

The entity's Board continually evaluates the distribution of duties to employees and closely monitors all accounting functions. The School District has implemented controls within its accounting functions to mitigate the lack of segregation of duties but recognizez that this should still be a concern for the School District and the Board.

View Audit 35995

Finding 34591 (2022-003)

Significant Deficiency 2022

City of Kotzebue, Alaska

AK

Procurement, Suspension & Debarment

Finding 2022-003 The Finance Department will verify prior to any purchase a vendor is not on the suspension and debarment list for covered transactions under Uniform Guidance. A copy of proof will be submitted with the check request and kept in the Accounts Payable file folder with vendor informatio...

Finding 2022-003 The Finance Department will verify prior to any purchase a vendor is not on the suspension and debarment list for covered transactions under Uniform Guidance. A copy of proof will be submitted with the check request and kept in the Accounts Payable file folder with vendor information. Estimated completion date: September 30, 2023

View Audit 32429

Finding 34590 (2022-002)

Significant Deficiency 2022

City of Kotzebue, Alaska

AK

Questioned Costs Procurement, Suspension & Debarment

Finding 2022-002 Finance Department will require a minimum of three quotes for any purchase above $10,000. Additionally, any purchase made above $50,000 will require a signed and approved Resolution from the City Council. The Finance Department will create and formally adopt a procurement process fo...

Finding 2022-002 Finance Department will require a minimum of three quotes for any purchase above $10,000. Additionally, any purchase made above $50,000 will require a signed and approved Resolution from the City Council. The Finance Department will create and formally adopt a procurement process for the City of Kotzebue to be approved by the City Council. Estimated completion date: September 30, 2023

View Audit 32429 Questioned Costs: $1

Finding 34589 (2022-002)

Significant Deficiency 2022

Wilkes County, North Carolina

NC

Questioned Costs Eligibility Significant Deficiency

Policy training is being completed with Medicaid staff to ensure all income and resources are correctly documented and applied in NC FAST. Second Party Reviews continue to be utilized in order to identify any eligibility determination deficiencies. Supervisors will give additional attention to AVS i...

Policy training is being completed with Medicaid staff to ensure all income and resources are correctly documented and applied in NC FAST. Second Party Reviews continue to be utilized in order to identify any eligibility determination deficiencies. Supervisors will give additional attention to AVS information and how it is documented in NC FAST when conducting reviews.

View Audit 31229 Questioned Costs: $1

Finding 34585 (2022-001)

Significant Deficiency 2022

Wilkes County, North Carolina

NC

Significant Deficiency Internal Control / Segregation of Duties

Additional training is being provided to DSS staff on importance of securing work areas and how breach may occur with workstations left unattended and unsecured. Computer workstations log out automatically after brief period of idle time, however staff have been instructed to use manual lock of work...

Additional training is being provided to DSS staff on importance of securing work areas and how breach may occur with workstations left unattended and unsecured. Computer workstations log out automatically after brief period of idle time, however staff have been instructed to use manual lock of workstations whenever stepping away from desk. Supervisors have also been instructed to do random visual checks of workstations.

View Audit 31229

Finding 34584 (2022-001)

Significant Deficiency 2022

Corry Memorial Hospital Association D/b/a Lecom Health Corry Memorial

PA

Special Tests & Provisions Student Financial Aid Significant Deficiency

Finding 2022-001: Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.4 of the Community Facilities Direct Loan agreement stipulates that the borrower must maintain funds in accounts in accord...

Finding 2022-001: Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.4 of the Community Facilities Direct Loan agreement stipulates that the borrower must maintain funds in accounts in accordance with Section 4 of the Loan Resolution. The Loan Resolution stipulates that the borrower must establish a General Account and Reserve Account. The Reserve account must be funded to an amount equaling or exceeding $1,167,219. Condition and Context: The Association did not have a specific Reserve Account established in accordance with the Loan Resolution. Corrective Action Plan: Corry Memorial Hospital Association d/b/a LECOM Health Corry Memorial Hospital and Subsidiaries agrees with the finding and will implement controls sufficient to identify and monitor ongoing compliance with requirements. Additionally, Corry Memorial Hospital Association d/b/a LECOM Health Corry Memorial Hospital and Subsidiaries will establish and fund the required reserve account. Contact Person: Tim McGahen, Chief Financial Officer 965 Shamrock Lane, Corry, PA 16407 Expected Date of Resolution: The policies are expected to be updated effective March 30, 2023. The Reserve account is expected to be established and funded by March 1, 2023.

View Audit 31227

Finding 34583 (2022-001)

Significant Deficiency 2022

Puerto Rico Planning Board

PR

Reporting

FINDING NUMBER 2022-001 Financial Management ? Accounting System and Reporting Practices PRIFAS is the official accountability of Puerto Rico?s Government. This system does not have compatibility with many sub-systems. The Department of the Treasury is working with the new accounting and financial ...

FINDING NUMBER 2022-001 Financial Management ? Accounting System and Reporting Practices PRIFAS is the official accountability of Puerto Rico?s Government. This system does not have compatibility with many sub-systems. The Department of the Treasury is working with the new accounting and financial system that would harmonize with government agencies and we hope to be ready in September 2023. The Puerto Rico Planning Board continues to monitor the Treasury Department in relation to this matter and to correct this finding. The Planning Board expects to complete it by 2023. Contact Official: Mr. Andres Ruiz, Finance Director

View Audit 35956

Finding 34578 (2022-001)

None 2022

City of Roanoke, Virginia

VA

Subrecipient Monitoring

D EPARTMEN T OF FINANCE Ci ty of Roanoke 215 Church Avenue, SW Roanoke, VA 240 11 (540) 853-28 24 www.roanok eva.gov CORRECTIVE ACTION PLAN March 29, 2022 The Federal Audit Clearinghouse: The City of Roanoke, Virginia respectfully submits the following corrective action plan for the year ended...

D EPARTMEN T OF FINANCE Ci ty of Roanoke 215 Church Avenue, SW Roanoke, VA 240 11 (540) 853-28 24 www.roanok eva.gov CORRECTIVE ACTION PLAN March 29, 2022 The Federal Audit Clearinghouse: The City of Roanoke, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 319 McClanahan St. SW, Roanoke, VA 24014 Audit period: June 30, 2022 The findings from the June 30, 2022 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT CY - Financial Statement - None CY- Federal Major Program 2022-001: Workforce Investment Opportunitv Cluster #17.258/17.259/17.278, Subrecipient Monitoring Assistance Listing Condition: During our review of subrecipient monitoring, we noted that the City's semi-annual subrecipient monitoring scheduled for February 2022 was not performed. Criteria: According to the City's Program Participant Monitoring Plan, the City is supposed to conduct subrecipient monitoring on a semi-annual basis which should include desk reviews of payroll, disbursements, and other financial items. Cause: Staff turnover, particularly for the role of grant accountant, caused these procedures to be overlooked. Effect: Noncompliance with federal grant requirements with regard to subrecipient monitoring as well as risk of subrecipient misusing funds. Questioned Cost Amount: Not applicable. Perspective Information: Not applicable. Recommendation: We recommend performing subrecipient monitoring in accordance with the City's guidelines and following the procedures laid out in the Program Participant Monitoring Plan. View of Responsible Officials and Planned Corrective Action: Management concurs with the recommendation and will ensure that follow up occurs regarding information provided by business owners. Loss of staff in this accountability area resulted in an inquiry and reviews conducted via electronic means verses a physical. Delivered information was reviewed and acknowledged by Accounting Supervisor, however physical visit did not occur. The Accounting Supervisor and the Accounts Payable Co-coordinator, in the absence of a Grant Accountant, have conducted the first semi-annual visit for FY23. Follow-up information has been received upon request and the final physical review has been scheduled for Spring of 2023. CY - Commonwealth - Auditor of Public Accounts - Fire Program A required audit procedure is to obtain a copy of the locality's completed Annual Report and Disbursement Agreement forms submitted to the Department of Fire Programs for the applicable fiscal year under audit. The procedure includes ensuring that the Annual Report and Disbursement Agreement forms are properly completed in accordance with Fire Programs' requirements and reconciled amounts per the Annual Report to the locality's accounting records. It was noted in the current year that the amount of revenues and expenditures reported to the Department of Fire Programs did not agree to the underlying accounting records. We recommend the Annual Report be reviewed and reconciled to the general ledger before submission. ManagementJs response: Management concurs with the recommendation and wilt ensure that follow up occurs regarding information provided. Employee transition and lack of training resulted in discrepancy. The Fire Program reports were submitted in advance of finalization of the disbursement register. This finding will be duplicated for FY22 report as well. Training has been provided, a procedure has been developed and the Accounting Supervisor is included in review of reporting prior to submission. PY - Financial Statement Audit Adjustments (Significant Deficiency) - Cleared PY - Federal Major Program COVID Business Grants - Cleared PY - Commonwealth - still applicable Disclosure Statements Five of 83 disclosure statements were not filed timely. Management's response: Management concurs with the recommendation and will ensure that follow up occurs regarding information provided. Staffing vacancies resulted in this delay. Training has been provided to new employee and an expectation of this issue being cleared is anticipated for FY23. Highway Maintenance Testing Six of the ten time cards tested contained data that could not be allocated to a specific work order. We recommend all departments use the newly adopted time reporting software to ensure labor is charged to the correct work order. Management concurs with the recommendation and will ensure that follow up occurs regarding information provided. [this testing is one year behind so improvements implemented in FY22 will be reflected in FY23 testing] PY - Commonwealth - no longer applicable Social Services - Special Welfare- Treasurer Reimbursements Social Services - Special Welfare- Unexpended Funds If the Federal Audit Clearinghouse has questions regarding this plan, please call Brent Robertson, Chief Financial Officer at (540) 853-1556. Respectfully submitted, Brent Robertson ACM/Chief Financial Officer

View Audit 35952

Finding 34577 (2022-003)

Material Weakness 2022

Heart of America Medical Center

ND

Reporting Material Weakness

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal ...

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Responsible Individuals: Melissa Shepard, CFO and Erik Christenson, CEO Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for a complete and accurate consolidated schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the consolidated schedule of expenditures. We have designated a member of management to review the drafted consolidated schedule of expenditures. Anticipated Completion Date: Ongoing

View Audit 33781

Finding 34576 (2022-006)

Significant Deficiency 2022

Onslow County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Re: Single County Audit Finding 2022-006, Significant Deficiency over Eligibility Cause: Caseworkers did not take proper steps ensuring what was used for eligibility determination was complete and accurate per program guidelines. Auditors Recommendation: Caseworkers should review eligibility deter...

Re: Single County Audit Finding 2022-006, Significant Deficiency over Eligibility Cause: Caseworkers did not take proper steps ensuring what was used for eligibility determination was complete and accurate per program guidelines. Auditors Recommendation: Caseworkers should review eligibility determinations and ensure all documentation is included and accurate. Corrective Action Plan: Agency realigned Medicaid to be under one Program Manager to ensure consistency with quality control and review. ? Program Manager, Supervisors, and Lead Workers created a Medicaid Quality Control plan to be followed by all units that includes pulling a random sample from each caseworker every month to include at least 2 approvals and 1 denial. ? The DHB 7078, Second Party Review Worksheet, is completed for each application or case pulled to ensure that policy and procedure is followed. The Explanation of Errors section is completed for any errors discovered and the completed DHB 7078 is then attached to an email and sent to the individual caseworker along with a detailed explanation providing policy and training materials, OST guidance, or emails that reinforce the decision to cite the error. As it relates specifically to the cited error above, the DHB 7078 section B. Documentation is used to review that all required documents are placed in the case record. ? Checklists have been created and are being utilized to prevent errors and all caseworkers have a copy of the DHB 7078 and are required to review prior to authorizing. ? When an error is discovered, the caseworker?s name, case number, and specific error are logged on a Quality Control spreadsheet. This spreadsheet is used to identify training issues and/or repetitive errors. The spreadsheet will be reviewed monthly by Supervisors and Lead Workers for their own unit and reviewed quarterly with all Medicaid Supervisors and Program Manager. ? Along with one-on-one emails that address the individual caseworker errors, group trainings will be held based on repetitive errors and knowledge checks will be utilized at the end of group trainings. ? If an individual caseworker has repeat findings after an error has been addressed there will be a meeting between the caseworker and the supervisor to discuss the issue. During this meeting, training, to include policy sections, training materials, OST guidance, and/or emails will be provided. The caseworker will be asked to sign a training acknowledgement form stating that they have received the training, understand the policy, have no questions, and understand that a full coaching will be implemented if the errors continue. The caseworker will have additional work reviewed for the next 30 days. Proposed Completion Date: Ongoing Name/ Position Contact Person: Kimberli Sholar, Medicaid Program Manager

View Audit 32534

Finding 34574 (2022-005)

Significant Deficiency 2022

Onslow County, North Carolina

NC

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Re: Single County Audit Finding 2022-005, Internal Control Significant Deficiency Cause: Turnover in the department left certain duties unfulfilled during part of the fiscal year. Auditors Recommendation: The County should have procedures in place to cover the second-party review process upon tur...

Re: Single County Audit Finding 2022-005, Internal Control Significant Deficiency Cause: Turnover in the department left certain duties unfulfilled during part of the fiscal year. Auditors Recommendation: The County should have procedures in place to cover the second-party review process upon turnover within the department. Corrective Action Plan: Program Manager, Supervisor and Lead Worker have developed a partnership and will share the responsibility of ensuring second-party reviews are conducted on all required cases. The Program Manager will assume this responsibility in their absence or if a position is vacated. ? The TANF Supervisor and Lead Worker will follow a TANF second-party review formula to ensure 25% of Work First cases will be reviewed for each caseworker, every month, to include applications and recertifications, as outlined in Work First policy. Second-party reviews will be completed weekly by the Lead Worker to ensure program compliance. ? The Lead Worker will log details of each case reviewed on the TANF second-party review log, to include any deficiencies noted. ? The Supervisor and Program Manager will review the log monthly to ensure program compliance, identify any performance issues, and ensure oversight. Errors identified will be addressed with the individual caseworker through emails and individual coaching. Proposed Completion Date: Ongoing Name/ Position Contact Person: Cindi Douglas, Program Manager

View Audit 32534

Finding 34572 (2022-007)

Significant Deficiency 2022

Onslow County, North Carolina

NC

Significant Deficiency Internal Control / Segregation of Duties

Re: Single County Audit Finding 2022-007, Internal Control Significant Deficiency Cause: Turnover in Supervisor position left duties unfulfilled and an unsigned DSS-1682, was located in one case file. Auditors Recommendation: The County should have procedures in place to cover the review process...

Re: Single County Audit Finding 2022-007, Internal Control Significant Deficiency Cause: Turnover in Supervisor position left duties unfulfilled and an unsigned DSS-1682, was located in one case file. Auditors Recommendation: The County should have procedures in place to cover the review process upon turnover within the department. Corrective Action Plan: Program Integrity unit is currently fully staffed, to include the Supervisor position. A contingency plan has been created to ensure coverage during absences and vacancies. ? The Program Integrity Supervisor will sign all DSS-1682 forms as required by policy. ? Once the DSS-1682 has been signed by the Program Integrity Supervisor, the unit processing assistant will review the form for completion and required signatures, prior to entering the claim data into the state system. ? The Program Manager will assume this responsibility if the Supervisor is absent or the position is vacated. Proposed Completion Date: Ongoing Name/ Position Contact Person: Cindi Douglas, Program Manager

View Audit 32534

Finding 34571 (2022-003)

Significant Deficiency 2022

Catholic Charities, Inc.

DE

Corrective Action Plan: Charities DEAP program has revised and implemented reconciliation procedures to ensure the program year 2022 heating reconciliation benefit report is completed on April 6, 2023. The final reconciliation report for the 2022 heating benefit refund will be remitted to the State ...

Corrective Action Plan: Charities DEAP program has revised and implemented reconciliation procedures to ensure the program year 2022 heating reconciliation benefit report is completed on April 6, 2023. The final reconciliation report for the 2022 heating benefit refund will be remitted to the State of Delaware Office of Community Services (OCS) in accordance with the established guidelines by April 14, 2023. Process of completion is performed manually: 1. The collection of delivered and non-delivered fuel vendors? unexpended benefits reports has been obtained from the non-delivered vendors. Completed November 2022 2. Inter-Agency households? report of benefits returned to the State of Delaware OCS for the heating season 2022 by the county and by invoice number is in process of being manually completed. 3. The documents noted in procedures 1 and 2 must reconcile with the DEAP billing supervisor report of heating benefits issued - funded and refunded by the vendors. The agency finance unit reporting of paid benefits vs refunded benefits must be compared to the noted reports to verify all report totals equal. 4. The unused benefit report noting the total amount to be returned to the State OCS, is completed once the agency finance unit verification of totals reported in procedures 2 and 3 are accurate for the 2021-2022 heating reconciliation. The program year 2022 reconciliation report will be completed according to OCS?s format and submitted along with the check from the agency for the total amount of the refund. Contact Person Responsible for Corrective Action: Fritz Jones, Executive Director Anticipated Completion Date of Corrective Action: April 6, 2023

View Audit 32532

Finding 34570 (2022-002)

Significant Deficiency 2022

Catholic Charities, Inc.

DE

Internal Control / Segregation of Duties

Corrective Action Plan: 1. In the instances of missing required documentation: Intake supervisors and workers will need to assure current copies of client leases and income verification documents are on file. Intake supervisors will continue to conduct random sampling case reviews quarterly, reporti...

Corrective Action Plan: 1. In the instances of missing required documentation: Intake supervisors and workers will need to assure current copies of client leases and income verification documents are on file. Intake supervisors will continue to conduct random sampling case reviews quarterly, reporting noted infractions and the correction of noted chart infractions. a. Intake workers will receive directions on the required documents and the functions of the documents that must be current and maintained in the client file. b. The intake worker will assure the reason given for zero income is accurately documented on the Zero Income form and in the client?s file. 2. In the instances of incorrect recording of client income and household size: Intake supervisors and workers will engage in quarterly in-service training to address household income verification, calculation, and verification of the household size to assure appropriate award of program benefits. a. The guidelines for the calculations of income for program 2023 benefits guidelines will be reviewed with Intake Supervisors to assure training of the sites Intake Worker. b. The Intake Supervisor will be required to verify the income calculations and the household size in relation to the awarded benefit as part of the quarterly case review. Contact Person Responsible for Corrective Action: Fritz Jones, Executive Director Anticipated Completion Date of Corrective Action: March 2023

View Audit 32532

Finding 34569 (2022-001)

Significant Deficiency 2022

Catholic Charities, Inc.

DE

Cash Management

Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 15, 2022 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollme...

Corrective Action Plan: Catholic Charities Program Manager, Joanne Varnes, conducted a training on December 15, 2022 with all staff involved in the CACFP that included income eligibility/enrollment categorization and meal count accuracy. Catholic Charities staff will review each income form/enrollment and double check that children?s reimbursement rate is properly categorized based on their family?s income. Staff members will review each claim before it is entered for reimbursement to ensure the claim is accurate. Program Manager, Joanne Varnes, will oversee this process and conduct case record reviews quarterly for all providers under Catholic Charities Sponsorship. Contact Person Responsible for Corrective Action: Fritz Jones, Executive Director Anticipated Completion Date of Corrective Action: Immediately

View Audit 32532

Finding 34564 (2022-001)

None 2022

East Oakland Community Project

CA

Procurement, Suspension & Debarment Eligibility

Corrective Action Plan: Auditee will implement checklist update, staff training, and approval process. - April-June 2023: update all client file checklists to insure they include all information required about each individual and benefits paid to or on behalf of the individual. - Beginning in April ...

Corrective Action Plan: Auditee will implement checklist update, staff training, and approval process. - April-June 2023: update all client file checklists to insure they include all information required about each individual and benefits paid to or on behalf of the individual. - Beginning in April 2023: provide training for staff to understand documentation requirements and adhere to checklists. - Monthly through Dec 2023, quarterly thereafter: managers/directors will review randomly selected files to ensure all necessary documents and approvals are included. Responsible Person Contact Information: Shari P Wooldridge Interim Executive Director 510-746-3602 shariw@eocp.net Anticipated Completion Date: 12/31/23

View Audit 24146

Finding 34562 (2022-001)

None 2022

Asi Woodlands Senior Housing, Inc.

MN

HUD Housing Programs

ASI WOODLANDS SENIOR HOUSING, INC. HUD PROJECT NO. 114-EE106 CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Woodlands Senior Housing, Inc. respectfully submits the following corrective action plan fo...

ASI WOODLANDS SENIOR HOUSING, INC. HUD PROJECT NO. 114-EE106 CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ASI Woodlands Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Hinrichs & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT NONE FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: SECTION 202, ASSISTANCE LISTING NUMBER 14.157 The Project's security deposit liability account was underfunded at June 30, 2022. Recommendation: The Project should carefully review the statement of financial position to make sure the security deposit liability account is funded. Action Taken: The Project agrees with the finding. Management will be reminded to review the tenant security deposit cash balance versus the security deposit liability balance on a monthly basis. This finding was corrected in September 2022. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.

View Audit 31105

Finding 34560 (2022-001)

None 2022

Kennedy Krieger Institute

MD

Reporting

In attesting to the methodology used to calculate lost revenue in accordance with the June 11, 2021 General and Targeted Distribution Post-Payment Notice of Reporting Requirements, Option (i) difference between actual patient care revenues was selected in the HRSA reporting portal. Differences in ac...

In attesting to the methodology used to calculate lost revenue in accordance with the June 11, 2021 General and Targeted Distribution Post-Payment Notice of Reporting Requirements, Option (i) difference between actual patient care revenues was selected in the HRSA reporting portal. Differences in actual patient care revenues were used in both the base and target periods, however, we made a modification to what was included in patient care revenue and only included those revenues generated through inpatient services and excluded patient care revenue generated from outpatient services. The rationale for including inpatient revenue and excluding outpatient revenue is detailed below. The pandemic impacted patient service revenue on the inpatient units by contributing to lower inpatient census for a variety of reasons. These reasons include mandatory infection control, patient distancing an isolation requirements and severe staffing shortages. All of our semiprivate and other multi-patient rooms were converted to private rooms to limit patient contact with other patients and their families during admission. Additionally, we only permitted patient admissions from Maryland and our neighboring states (State mandates), thereby limiting the patient admission pool. Last, the pandemic created severe staffing shortages in nursing, therapy and clinical aids thereby requiring reduced admissions for patient safety reasons. The shortages occurred due staff COVID infection, exposure, isolation and other limitations on their ability to perform their jobs. These factors drove down inpatient admissions, patient days and the related patient service revenue levels as compared to pre-pandemic levels. At the outset of the pandemic, outpatient operations were essentially shut down with very few patients seen. However, within 2 to 4 weeks from pandemic outset, we were able to effectively pivot operations from a completely on-site operation to providing services to more than 20,000 outpatient visits through tele-health. Using tele-health, patients were able to see their clinical providers from their home via a Zoom link. Same was true for the clinical providers. The quick transition to tele-health really limited the impact that the pandemic had on outpatient operations and specifically limited lost revenue to only a couple weeks. The quick change in the method of care delivery between on-site services and services rendered by telehealth had a significant impact on provider productivity and the type of revenue recognized. It was determined that these differences did not allow for an accurate apples to apples comparison of patient service revenue pre-pandemic versus during the pandemic. We concur with the finding that Option (iii) should have been selected as the methodology used in determining lost revenue for Provider Relief Fund reporting. We plan to make the necessary corrections to the change in methodology for period 1 & 2 reporting while submitting our period 4 reporting by March 31. 2023. HRSA was contacted before September 30, 2022 and we were instructed that any changes in methodology would need to be made during our next open reporting period. This window has just opened on January 1, 2023 and corrections will be made for this reporting methodology by March 31, 2023. We plan to make the necessary corrections to the change in methodology for period 1 & 2 reporting while submitting our period 4 reporting by March 31. 2023.

View Audit 31104

Corrective Action Plans

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