Corrective Action Plans

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Finding 12723 (2022-001)
Significant Deficiency 2022
In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in Novemb...
In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in November of 2018, we added presence of the financial assessment form to the compliance review process. The compliance percentage of that measure is reported monthly to staff and also to the Quality Performance Review Committee of the board of directors. Our internal tracking indicates compliance now exceeds 98%. We will continue the monitoring and education efforts and expect to move toward full compliance.
Finding 12722 (2022-001)
Material Weakness 2022
Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund porta...
Finding 2022-001 Federal program: Provider Relief Fund Assistance Listing Number 93.498 Statement of Condition For 2 of 40 samples of expenditures, the expenditure claimed represented an amount that was claimed twice by the Company in their expenditures reporting in the Provider Relief Fund portal. Additionally, Legacy claimed expenses that were duplicated within the reporting portal. The general distribution report for Legacy Health for Period 1 shows $35,760,843 in expenses applied against the PRF funds in the PRF portal report for Legacy as a consolidated entity. Separately, the stand-alone reports for targeted funds received by Emanuel Hospital & Health Center for Period 1, Legacy Silverton Medical Center for Period 1, Legacy Clinics, LLC for Period 1, and Legacy Meridian Park Hospital for Period 2 also include expenses totaling $12,291,293 that are included in the $35,760,843 listed in the consolidated report above. This results in duplicate reporting of the same expenditures. During testing over reporting and allowability it was observed that the lost revenues attributable to Coronavirus were reported in both the parent entity?s PRF reports on the general distribution payments and the subsidiary entities? PRF reports on the targeted distribution payments (i.e., lost revenues were duplicated). Lost revenues shown on the subsidiary reports as available to be applied against PRF that related to lost revenues also reported in the parent entity?s report were related to Emanuel Hospital & Health Center for Period 1 in the amount of $27,106,110 and Legacy Silverton Medical Center for Period 1 in the amount of $10,269,349. Actions Taken and Status As noted within the portal filing summary, for reporting period 1, Legacy consolidated COVID-19 expenses ($35,760,843) plus lost revenue ($150,037,450) totaled $185,798,293. Payments from the PRF totaled $89,818,954. As a result, there were sufficient qualifying lost revenues to receive and earn all PRF funds received, regardless of the questioned costs above. Therefore, management believes no repayment of PRF funds received would be required. Further, management considered the finding. Reporting for the Legacy parent reporting entity was based on the ?Post-Payment Notice of Reporting Requirements (6/11/21)?, which includes the following requirement: ?Reporting entities will submit consolidated reports.? Neither the methodology utilized by Legacy or application of the methodology advocated by KPMG result in repayment of any of the funds received from the PRF. Management is implementing a process to identify and resolve situations in which reporting requirements are inconclusive, in conflict, or ambiguous. Outside subject matter expertise will be accessed as needed. Person responsible for the implementation of the corrective action plan: Tom Haywood Legacy Health 1919 NW Lovejoy St Portland OR 97219 503-415-5793 thaywood@lhs.org
View Audit 17558 Questioned Costs: $1
Finding 12721 (2022-003)
Significant Deficiency 2022
FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verificati...
FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verification with funders should be performed as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name(s) of the contact person(s) responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.
Finding 12720 (2022-006)
Significant Deficiency 2022
Department of Veterans Affairs 2022-006 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: We recommend the Inner Voice review its policies and procedures at the conclusion of an award period and obtain authorization from the federal awarding agency for...
Department of Veterans Affairs 2022-006 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: We recommend the Inner Voice review its policies and procedures at the conclusion of an award period and obtain authorization from the federal awarding agency for costs incurred after the award period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Inner voice has approached VA Authority on this issue and they have no issue as this cost is immaterial. However, moving forward Inner voice will not allocate cost to the program and grant unless work is completed or approved by the funder in instances where the work cannot be completed during the program year. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: Effective immediately.
Finding 12719 (2022-005)
Significant Deficiency 2022
2022-005 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: The Inner Voice should implement a procurement policy and procedure that includes the selection and documentation of procurement rationale, controls and oversight. This policy should be follow...
2022-005 VA Homeless Providers Grant and Per Diem Program ? Assistance Listing No. 64.024 Recommendation: The Inner Voice should implement a procurement policy and procedure that includes the selection and documentation of procurement rationale, controls and oversight. This policy should be followed for all procurement transactions and include compliance requirements UG ?200.318 general procurement standards, UG ?200.319 competition, and ?200.320 methods of procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policy is drafted and under discussion before bring this to the Board for a formal approval and its implementation. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: After the approval of the Board that is planned to be held during the month of March.
Finding 12718 (2022-004)
Significant Deficiency 2022
FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verificati...
FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Treasury 2022-003 American Rescue Plan Act ? Assistance Listing No. 21.027 Recommendation: We recommend Inner Voice establish controls to evaluate grant agreements to capture funds identified as federal. Upon preparation of the SEFA, verification with funders should be performed as needed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name(s) of the contact person(s) responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.
Finding 12717 (2022-002)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY 2022-002 Audit misstatements Recommendation: We recommend that management review policies and procedures over year-end transactions to ensure that all necessary adjustments are being posted on a timely basis, in the appropriate period, and in accordance with generally accep...
SIGNIFICANT DEFICIENCY 2022-002 Audit misstatements Recommendation: We recommend that management review policies and procedures over year-end transactions to ensure that all necessary adjustments are being posted on a timely basis, in the appropriate period, and in accordance with generally accepted accounting principles. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.
MATERIAL WEAKNESS 2022-001 Financial Reporting Recommendation: The financial statement preparation process s...
MATERIAL WEAKNESS 2022-001 Financial Reporting Recommendation: The financial statement preparation process should be part of the internal control system, although the Inner Voice may be financially limited in the hiring of personnel with an up-to-date understanding of accounting preannouncements, proper mitigating factors should be reflected including oversight by management. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are in the process of discussing with the Board for hiring of a finance person to prepare the reports so that CFO can review and approve his/her work. Name of the contact person responsible for corrective action: CFO Planned completion date for corrective action plan: September 1, 2023.
2022-001 ? ALN 14.871 ? Section 8 Housing Choice Vouchers Program - Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executiv...
2022-001 ? ALN 14.871 ? Section 8 Housing Choice Vouchers Program - Eligibility Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023 2022-002 ? Significant Deficiencies in Internal Controls over Financial Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Tyronnda Bethune, Executive Director Projected Completion Date: September 30, 2023
Research and Development Assistance Listing No Various Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Research and Development Assistance Listing No Various Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs. Departments are entrusted with considerable latitude in determining needs and purchasing products, services, and technical support required to perform educational and outreach duties as well as research with sponsored projects. Because of this, it is reasonable for departments to verify the delivery of these purchases, establish the quality and quantity of the items, and begin the process of paying the corresponding invoices. Delays in the workflow sometimes occur due to valid reasons, and other times are due to a breakdown in the administrative process. Information will be shared with departments regarding delays in invoice processing. This will include sharing the information with academic and research heads in the colleges that processing of invoices must occur quickly, discrepancies affecting the expedient payments will be noted on invoices, and explanations will be recorded. Name(s) of the contact person(s) responsible for corrective action: Robert Dixon, Director of Grants and Contracts Financial Administration Planned completion date for corrective action plan: Spring 2023
2022-004 UNTIMELY FILING OF THE DATA COLLECTION FORM ? OTHER NONCOMPLIANCE Condition: The Kindred Public School District did not submit its Data Collection Form to the Federal Audit Clearinghouse within nine months of its year-end. Corrective Action Plan: Agree?We had many things going on this ...
2022-004 UNTIMELY FILING OF THE DATA COLLECTION FORM ? OTHER NONCOMPLIANCE Condition: The Kindred Public School District did not submit its Data Collection Form to the Federal Audit Clearinghouse within nine months of its year-end. Corrective Action Plan: Agree?We had many things going on this year with Superintendent hiring and construction. Anticipated Completion Date: Was done as soon as audit was complete.
SIGNIFICANT DEFICIENCY: 2022-003 In-Kind Procedures: Criteria ? The Authority is responsible for establishing and maintaining internal controls for recording in-kind revenues & expenses. Condition ? During the performance of our audit, it was determined that the review proced...
SIGNIFICANT DEFICIENCY: 2022-003 In-Kind Procedures: Criteria ? The Authority is responsible for establishing and maintaining internal controls for recording in-kind revenues & expenses. Condition ? During the performance of our audit, it was determined that the review procedures for in-kind revenues and expenses were not adequate for identifying if improper amounts were recorded. Cause ? The Authority has not designed adequate procedures for reviewing in-kind revenues and expenses. Effect ? As a result of these inadequate procedures, there is a higher threat that errors or improper amounts could be recorded as in-kind revenues and expenses. Recommendation ?The Authority should review and revise procedures to ensure in-kind revenues and expenses are being properly recorded and reviewed. Client?s Response ? We will review our current procedures to ensure in-kind revenues and expenses are properly reviewed and recorded in the financial statements in the future.
2022-001: Audit Adjustments and Oversight of the Financial Reporting Process Name of contact person: Kris Meyer, Director of Operations Corrective Action: The Corporation continues to work on educating their new team and implementing good financial statement review processes. Management also intends...
2022-001: Audit Adjustments and Oversight of the Financial Reporting Process Name of contact person: Kris Meyer, Director of Operations Corrective Action: The Corporation continues to work on educating their new team and implementing good financial statement review processes. Management also intends to implement a simplified development accounting process going forward. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.
2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and ...
2022-002: Lack of Documentation for Review of Tenant Files Name of contact person: Nancy Cashman, Executive Director Corrective Action: The Corporation created written policies and procedures for affordable housing program compliance and review of the applicable tenant files in fiscal year 2023 and is in the process of adopting these policies and procedures. Proposed completion date: The Organization plans to complete the plan by September 30, 2023.
Recommendation: CASA should ensure better document the recertification and HUD tenant assistance payment process to ensure new staff are aware of all required procedures. Further, CASA should ensure adequate training is being provided to all new staff in this role. Views of Responsible Officials an...
Recommendation: CASA should ensure better document the recertification and HUD tenant assistance payment process to ensure new staff are aware of all required procedures. Further, CASA should ensure adequate training is being provided to all new staff in this role. Views of Responsible Officials and Planned Corrective Actions: Personnel have now been properly trained on entering information after recertification occurs. Further, these procedures are now documented.
View Audit 18072 Questioned Costs: $1
Contact Person: Jessica Park, CFO Finding 2022-001 Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program?s vendor. Condition...
Contact Person: Jessica Park, CFO Finding 2022-001 Subrecipient Monitoring AL 93.778 Medical Assistance Program and DHS Medical Assistance Criteria: PA DHS compliance require the County to perform subrecipient monitoring procedures over MATP funding disbursed to the Program?s vendor. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program?s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program?s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year ? Finding 2021-001. Questioned Costs: The amount of questioned costs, if any, is undeterminable Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored. Management Response: Management maintains that they do not have adequate controls or proper expertise to monitor the vendor. Management will contract a firm to provide oversight over the vendor. Anticipate Completion Date: Immediate Respondent: (Name, Title, Department, Address): Jessica Park CFO Jefferson County 155 Main Street, 2nd Floor Brookville PA 15825
Jefferson County 155 Main Street, 2nd Floor Brookville PA 15825 Contact Person: Jessica Park, CFO Finding 2022-004 Reporting AL 93.659 Adoption Assistance and DHS Children and Youth Agency Programs Criteria: PA DHS and Uniform Guidance compliance require the County to submit Act 148 reports...
Jefferson County 155 Main Street, 2nd Floor Brookville PA 15825 Contact Person: Jessica Park, CFO Finding 2022-004 Reporting AL 93.659 Adoption Assistance and DHS Children and Youth Agency Programs Criteria: PA DHS and Uniform Guidance compliance require the County to submit Act 148 reports in a timely manner. Condition: During the audit, it was noted that the County was not submitting the reports in a timely manner. Cause: The County does not have adequate controls in place or the expertise to submit reports in a timely manner. Effect: The County was not in compliance with the terms of the grant program. Questioned Costs: The amount of questioned costs, if any, is undeterminable Recommendation: The County should implement internal control procedures to follow the compliance requirements of the program. Management Response: Management will implement internal control procedures and positions of expertise to submit reports in a timely manner. Anticipate Completion Date: Immediate Respondent: (Name, Title, Department, Address): Jessica Park CFO Jefferson County 155 Main Street, 2nd Floor Brookville PA 15825
Contact Person: Jessica Park, CFO Finding 2022-002 Subrecipient Monitoring AL 21.023 Emergency Rental Assistance Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program?s vendor. Condition: During...
Contact Person: Jessica Park, CFO Finding 2022-002 Subrecipient Monitoring AL 21.023 Emergency Rental Assistance Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program?s vendor. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program?s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program?s vendor may be using grant funding inappropriately. This is a repeat finding from the prior year ? Finding 2021-002. Questioned Costs: The amount of questioned costs, if any, is undeterminable Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored. Management Response: Management maintains that they do not have adequate controls or proper expertise to monitor the vendor. Management will contract a firm to provide oversight over the vendor. Anticipate Completion Date: Immediate Respondent: (Name, Title, Department, Address): Jessica Park CFO Jefferson County 155 Main Street, 2nd Floor Brookville PA 15825
Finding 12636 (2022-010)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY 2022-010 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Allowable Costs or Cost Principles Condition Admin expenses reported under the program did not have proper supporting documentation to reflect the salary or wages associated with the sp...
SIGNIFICANT DEFICIENCY 2022-010 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Allowable Costs or Cost Principles Condition Admin expenses reported under the program did not have proper supporting documentation to reflect the salary or wages associated with the specific grant activities. Recommendation We recommend that the College review its controls and ensure that controls are implemented that meet Federal requirements related to payroll documentation. Actions Taken As of March 23, 2023, all personnel working on federal grants whose salary or wage expenses will be paid wholly or in part by the federal funding will be required to prepare a Personnel Activity Report to track time spent on grant vs non-grant activities.
Finding 12634 (2022-011)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY 2022-011 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Reporting Condition Evidence of the date that quarterly reports were uploaded to the College?s website were not saved, and during inquiry with key personnel, it was determined that not ...
SIGNIFICANT DEFICIENCY 2022-011 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Reporting Condition Evidence of the date that quarterly reports were uploaded to the College?s website were not saved, and during inquiry with key personnel, it was determined that not all of the reports were uploaded within 10 days following the quarter end. The reports later had to be amended to add required information and update expense amounts, and the changes were not conspicuously noted or dated. In addition, errors were noted within the annual report. Recommendation We recommend that the institution implement controls to ensure that reports are completed timely and accurately, and that evidence of submission or upload dates is saved. Actions Taken As of March 23, 2023, evidence of public posting dates will be saved during the publishing process. In addition, a reconciliation has been implemented in which an individual other than the preparer will review the report for accuracy prior to submission or publication.
MATERIAL WEAKNESS 2022-009 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Activities Allowed or Unallowed Condition Students were awarded HEERF aid in June 2022 based upon their outstanding account balance, and they were not given the option to take the disburseme...
MATERIAL WEAKNESS 2022-009 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Activities Allowed or Unallowed Condition Students were awarded HEERF aid in June 2022 based upon their outstanding account balance, and they were not given the option to take the disbursement as anything other than a credit to their account. Recommendation We recommend that the institution carefully review guidance regarding new funding sources in order to ensure that all applicable requirements are being met. Actions Taken As of April 1, 2023, the College has contacted the Department of Education in order to determine how best to remedy the situation and will take all actions recommended.
View Audit 17529 Questioned Costs: $1
MATERIAL WEAKNESS 2022-008 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Cash Management Condition During testing, it was discovered that funding was drawn down and not disbursed within the required timeframes. Recommendation We recommend that the College revie...
MATERIAL WEAKNESS 2022-008 Education Stabilization Fund ? Higher Education Emergency Relief Fund ? 84.425 ? Cash Management Condition During testing, it was discovered that funding was drawn down and not disbursed within the required timeframes. Recommendation We recommend that the College review its reconciliation process and implement controls to ensure that funding is disbursed within the correct timeframe after being drawn down. Actions Taken As of March 23, 2023, federal funding will only be drawn on a reimbursement basis in order to ensure that funds are disbursed within the required cash management timeframe.
View Audit 17529 Questioned Costs: $1
Finding 12631 (2022-007)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct ...
SIGNIFICANT DEFICIENCY 2022-007 Student Financial Assistance Program Cluster ? Title IV ? Eligibility Condition During testing, it was discovered that two students were over awarded subsidized direct loans. Recommendation We recommend that the institution implement controls to ensure that direct loan award amounts are reviewed for accuracy prior to making awards to students. Actions Taken As of March 23, 2023, the College has begun to implement a review of student awards that will include reviewing all aid and credits that the student is receiving and double checking NSLDS loan amount limits.
Finding 12628 (2022-006)
Significant Deficiency 2022
SIGNIFICANT DEFICIENCY 2022-006 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, it was discovered that COD reflected inaccurate disbursement amounts for two students. Recommendation We recommend that the institution review its reconciliation proce...
SIGNIFICANT DEFICIENCY 2022-006 Student Financial Assistance Program Cluster ? Title IV ? Reporting Condition During testing, it was discovered that COD reflected inaccurate disbursement amounts for two students. Recommendation We recommend that the institution review its reconciliation process and implement controls to ensure that COD records accurately reflect actual disbursements. In addition, we recommend that the institution implement a control to ensure that all completed verifications have been reported to COD. Actions Taken As of March 23, 2023, COD records have been updated for the two students in question. In addition, communication is ongoing with the College?s software provider in order to work towards a control that will ensure that this error does not occur again. Lastly, the College has implemented a review process to ensure that applicable students have completed their verification, and the third-party vendor who completes the verification process has been contacted about setting up a notification system to alert personnel when a student completes their verification.
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