Corrective Action Plans

Finding 6865 (2022-001)

Significant Deficiency 2022

TX

Effective fiscal year 2023, Good Neighbor Settlement House, Inc will monitor and produce a monthly report of federal expenditures. This action plan will allow Good Neighbor Settlement House, Inc to identify at the end of each fiscal year the need for a Single Audit.

View Audit 8816

Finding 6843 (2022-004)

Material Weakness 2022

Community Health and Emergency Services, Inc.

IL

Reporting Internal Control / Segregation of Duties

FINDING NO. 2022-004: Ineffective Internal Controls over Expenditure Report Preparation Condition: The Organization’s internal controls over the preparation and review of grant expenditure reports were not properly followed during the current fiscal year. Certain expenditure reports submitted to ...

FINDING NO. 2022-004: Ineffective Internal Controls over Expenditure Report Preparation Condition: The Organization’s internal controls over the preparation and review of grant expenditure reports were not properly followed during the current fiscal year. Certain expenditure reports submitted to HRSA were not timely filed: • The Medicaid cost report is due to Illinois Healthcare and Family Services (HFS) within 180 days after the close of the Clinic’s fiscal year. The Organization filed this report on September 8, 2022 for year-end June 30, 2021. • The Medicare cost report is due to Centers for Medicare & Medicaid Services (CMS) on November 30th, 2021 but was not submitted until December 6, 2021 Plan: CHESI is implementing procedures to ensure all reports are filed timely to avoid being out of compliance. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO

View Audit 8765

Finding 6842 (2022-003)

Material Weakness 2022

Community Health and Emergency Services, Inc.

IL

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were miss...

FINDING NO. 2022-003: Ineffective Internal Controls over Sliding Fee Revenues Condition: During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted the following exceptions: • Three (3) out of thirty-four (34) were missing applications. • Fourteen (14) out of thirty-four (34) sliding fee adjustments were calculated incorrectly based on the sliding fee schedule. • One (1) out of thirty-four (34) sliding fee adjustments were not properly applied to the patient’s account. Plan: CHESI has implemented a new workflow process to ensure compliance with the program requirements of the sliding fee program. CHESI has developed a new sliding fee procedure and trained all staff to ensure the applications are complete and signed by the patient, income is verified, the proper discount is calculated based on the sliding fee schedule, the proper amount of discount is applied to the patient’s account, and the application is approved and signed by the Billing Manager. All sliding fee applications will also be scanned into the patient’s chart once completed and approved. Anticipated Date of Completion: December 31, 2023 Name of Contact Person: Kanci Houston, CEO

View Audit 8765

Finding 6780 (2022-001)

Significant Deficiency 2022

Greylock Federal Credit Union

MA

Reporting

Establish procedures to reconcile the general ledger to expenditures reported to government agencies. Create a separate liability account for each award with a corresponding schedule identifying the purpose and required use of the funds and basic requirements such as the period of performance to en...

Establish procedures to reconcile the general ledger to expenditures reported to government agencies. Create a separate liability account for each award with a corresponding schedule identifying the purpose and required use of the funds and basic requirements such as the period of performance to enhance monitoring and tracking. Develop written accounting procedures for recognition of expenditures and grant income. Provide training and resources to staff involved in federal award compliance and reporting.

View Audit 8704

Finding 6774 (2022-001)

Material Weakness 2022

Winlock School District No. 232

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Winlock School District No. 232 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regu...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Winlock School District No. 232 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate controls for ensuring compliance with federal requirements for allowable costs and cost principles. Name, address, and telephone of District contact person: Gloria Dupree, Business Manager, N.E. 1st Street, Winlock, WA 98596, (360) 785-3582 Corrective action the auditee plans to take in response to the finding: Corrective actions for ensuring compliance with federal requirements around cash management, allowable costs, and cost principles. Cash Management 1. Review Policies and Procedures: Ensure the district’s policies and procedures align with federal standards. Regularly audit your cash management practices. 2. Training: Ensure training on federal regulations and the importance of adhering to them for staff members involved in cash management. 3. Internal Controls: Strengthen internal controls to prevent and detect non-compliance, including segregation of duties and regular reconciliations. We hired a new Accounts payable employee in February 2023. 4. Monitoring: Monitor regularly to ensure that federal funds are utilized properly and efficiently. Allowable Costs 1. Guidance Review: Review the federal awarding agency’s guidance on allowable costs to ensure that all costs charged to the award are permissible under the specific federal program. Office of the Washington State Auditor sao.wa.gov 2. Documentation: Implement a robust system to document all costs and ensure they are reasonable, allocable, and necessary. 4. Review: Conduct regular reviews of expenditures to check for compliance with allowable cost principles. 5. Training: Educate all staff involved in financial management about the principles of allowable costs associated with federal awards. Cost Principles 1. Policy Update: Update organizational policies to reflect federal cost principles. 2. Consistency: Apply costs consistently and in a manner consistent with policies and procedures. 3. Direct vs. Indirect Costs: Properly identify direct and indirect costs and allocate them according to federal standards. 4. Record Keeping: Maintain accurate and complete financial records, retaining them for the period specified by the federal award or until all audits are completed and findings resolved. Anticipated date to complete the corrective action: 02/01/2024

View Audit 8703 Questioned Costs: $1

Finding 6773 (2022-007)

Significant Deficiency 2022

County of Hidalgo, Texas

TX

Reporting

2022-007 Hidalgo County – ERAP Reporting Emergency Rental Assistance Program – ALN 21.023 Recommendation – We recommend the County implement controls to ensure reports are submitted timely by the required due date. Corrective Action Plan – The grant ended; therefore, reporting is no longer required....

2022-007 Hidalgo County – ERAP Reporting Emergency Rental Assistance Program – ALN 21.023 Recommendation – We recommend the County implement controls to ensure reports are submitted timely by the required due date. Corrective Action Plan – The grant ended; therefore, reporting is no longer required. Proposed Completion Date – Reporting is no longer required. Contact Person – Letty Chavez, First Assistant Country Auditor, County Auditor’s Office

View Audit 8702

Finding 6770 (2022-006)

Significant Deficiency 2022

County of Hidalgo, Texas

TX

Reporting

2022-006 Hidalgo County - CSLFRF Reporting Coronavirus State and Local Fiscal Recovery Funds – COVID-19 - ALN 21.027 Recommendation - We recommend internal controls be implemented to include a review and approval of the required reports prior to submittal. The review and approval should be documente...

2022-006 Hidalgo County - CSLFRF Reporting Coronavirus State and Local Fiscal Recovery Funds – COVID-19 - ALN 21.027 Recommendation - We recommend internal controls be implemented to include a review and approval of the required reports prior to submittal. The review and approval should be documented by being signed and dated by the preparer and reviewer. We also recommend for internal controls be implemented to ensure timely submission by the required deadlines. Corrective Action Plan – The reports were submitted late in the past due to employee turnover; however, procedures were implemented and the 2023 1st quarter report and all the reports thereafter have been submitted on time. We agree that procedures should be implemented to ensure that the reports are reviewed and approved prior to submittal. All reports will be prepared, reviewed, and approved by different individuals prior to being submitted. Proposed Completion Date – Immediately Contact Person – Letty Chavez, First Assistant County Auditor, County Auditor’s Office

View Audit 8702

Finding 6675 (2022-003)

Material Weakness 2022

Human Resource Development Institute

IL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting U.S. Department of Health and Human Services, AL No. 93.958, Block Grant for Community Mental Health Services U.S. Department of Health and Human Services, AL No. 93.959, Block Grant for Prevention and Treatment o...

Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting U.S. Department of Health and Human Services, AL No. 93.958, Block Grant for Community Mental Health Services U.S. Department of Health and Human Services, AL No. 93.959, Block Grant for Prevention and Treatment of Substance Abuse U.S. Department of Health and Human Services, AL No. 21.027, Coronavirus State and Local Fiscal Recovery Fund U.S. Department of Health and Human Services, AL No 93.778, Medicaid Cluster Medical Assistance Program Criteria Human Resources Development, Inc., and Affiliates’ (HRDI) is responsible for keeping an accurate accounting and all of the required documentation in accordance with applicable federal regulations. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll & Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • HRDI’s Human Resources has implemented quarterly audits on all new staff to verify each new staff member hired within the last year has a signed employee offer and appropriate backup support to support the employees’ annual salary. • HRDI has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • HRDI is in the process of implementing a new payroll & HRIS – UKG. The anticipated completion date is March 2024. All manual and onboarding processes will be implemented within the system for tracking and auditing purposes. • HRDI will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to handle any assigned task. All monthly entries are required reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. • All Grant related Year-End and Audit Procedures will be transitioned to the Grant Accountant who has experience in audits, compliance, and reporting of City, State, Local, and Federal Grants. • HRDI will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. • HRDI will ensure that Finance staff will receive at minimum of 25 hours of training each year related to GASB, GAAP, Governmental Financial Reporting, or other related accounting trainings annually. • HRDI will ensure that any staff involved in Financial Reporting that the technical expertise to help with the preparation, review, and analysis of the financial statements. The target date for implementation is March 31, 2024. The responsible party for the planned resources will be Gail ViJuk, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615..

View Audit 8675 Questioned Costs: $1

Finding 6674 (2022-002)

Material Weakness 2022

Human Resource Development Institute

IL

Questioned Costs Reporting Material Weakness

U.S. Department of Housing and Urban Development, CFDA No. 14.267, Shelter Plus Care U.S. Department of Housing and Urban Development, CFDA No. 14.241, Housing Opportunities for Persons with AIDS Passed-through Alabama Department of Mental Health and Retardation, AL No. 93.778, Medicaid Cluster Medi...

U.S. Department of Housing and Urban Development, CFDA No. 14.267, Shelter Plus Care U.S. Department of Housing and Urban Development, CFDA No. 14.241, Housing Opportunities for Persons with AIDS Passed-through Alabama Department of Mental Health and Retardation, AL No. 93.778, Medicaid Cluster Medical Assistance Program The 2022-002 finding expands finding 2022-001 for the federal award program as it impacted the expenses charged to the federal awards above. Prior to the adjustments to correct the balances, the expenses reported on the SEFA for AL No. 14.267 were overstated by approximately $3,015 and the expenses reported on the SEFA for AL No. 14.241 were overstated by approximately $37,649. In addition, the expenses reported on the SEFA for AL No. 93.778 were overstated by approximately $456,701. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. The Chief Financial Officer has been hired in December 2023 and will begin full time employment January 1, 2024. In addition, all Finance responsibilities currently handled by outsourced resources will be transitioned to full-time employed Finance staff. • All Grant related Year-End and Audit Procedures will be transitioned to the new Grant Accountant who has experience in audits, compliance, and reporting of City, State, Local, and Federal Grants. • HRDI will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. • HRDI will ensure that Finance staff will receive at minimum of 25 hours of training each year related to GASB, GAAP, Governmental Financial Reporting, or other related accounting trainings annually. • HRDI will ensure that any staff involved in Financial Reporting has the technical expertise to help with the preparation, review, and analysis of the financial statements. The target date for implementation is March 31, 2024. The responsible party for the planned resources will be Gail ViJuk, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615.

View Audit 8675 Questioned Costs: $1

Finding 6673 (2022-001)

Material Weakness 2022

Human Resource Development Institute

IL

Questioned Costs Material Weakness Reporting

Criteria Human Resources Development, Inc. and Affiliates’ (HRDI) is responsible for keeping an accurate accounting of its financial information. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the fi...

Criteria Human Resources Development, Inc. and Affiliates’ (HRDI) is responsible for keeping an accurate accounting of its financial information. Views of Responsible Officials and Planned Corrective Actions: HRDI will implement the following corrective actions for the FY 2023-24 to remediate the finding and address the cause of the finding. HRDI will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to manage any assigned task. All monthly entries that are required will be reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. •HRDI will implement balance sheet reconciliations to be prepared and completed by Finance Staff Accountants monthly with a monthly review performed by the Chief Financial Officer. All balance sheet accounts will be reconciled to external data for verification monthly. All revenue accounts will be reconciled to external data for verification monthly. •The Chief Financial Officer has been hired in December 2023 and will begin full time employment January 1, 2024. In addition, all Finance responsibilities currently handled by outsourced resources will be transitioned to full-time employed Finance staff. •HRDI will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. •HRDI will ensure that Finance staff will receive at minimum of 25 hours of training each year related to GASB, GAAP, Governmental Financial Reporting, or other related accounting trainings annually. •HRDI will ensure that any staff involved in Financial Reporting has the technical expertise to help with the preparation, review, and analysis of the financial statements. •HRDI has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants, contracts reporting, and compliance. The target date for implementation is March 31, 2024. The responsible party for the planned resources will be Gail ViJuk, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615.

View Audit 8675 Questioned Costs: $1

Finding 6650 (2022-002)

Significant Deficiency 2022

Lake of the Woods County

MN

Reporting

Name of Contact Person Responsible for Corrective Action: County Board and Lorene Hanson, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and report...

Name of Contact Person Responsible for Corrective Action: County Board and Lorene Hanson, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and reporting package. Comments: The late audit report was beyond the control of the county. The County Auditor/Treasurer will monitor the progress of the annual audit in the future so that the annual audit will be completed on a timely basis as described in our corrective action plan. Anticipated completion date: December 31, 2023

View Audit 8605

Finding 6649 (2022-002)

Significant Deficiency 2022

Lake of the Woods County

MN

Reporting

Name of Contact Person Responsible for Corrective Action: County Board and Lorene Hanson, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and report...

Name of Contact Person Responsible for Corrective Action: County Board and Lorene Hanson, County Auditor/Treasurer Corrective Action Planned: Future annual county audits will be completed within nine months of the fiscal year end to allow for timely submission of the data collection form and reporting package. Comments: The late audit report was beyond the control of the county. The County Auditor/Treasurer will monitor the progress of the annual audit in the future so that the annual audit will be completed on a timely basis as described in our corrective action plan. Anticipated completion date: December 31, 2023

View Audit 8604

Finding 6608 (2022-002)

Significant Deficiency 2022

Agricultural Enterprises Development Administration

PR

Significant Deficiency Matching / Level of Effort / Earmarking Special Tests & Provisions

We designed and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not legible. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the f...

We designed and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not legible. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the farmer a certification attesting that he/she redeemed the voucher.

View Audit 8540

Finding 6607 (2022-004)

Significant Deficiency 2022

Agricultural Enterprises Development Administration

PR

Allowable Costs / Cost Principles Cash Management Reporting

The Cost Allocation Plan is being drafted and will be submitted to the regulatory agency when the attendance and payroll program systems are fully implemented.

View Audit 8540

Finding 6606 (2022-003)

Significant Deficiency 2022

Agricultural Enterprises Development Administration

PR

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

We designated and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not stamped. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the...

We designated and trained personnel to work with the bank statements to identify timely any voucher in which the farmer identifier is not stamped. In those cases, a copy of the voucher must be sent to the Auxiliary Market Director to proceed to identify the farmer appropriately and request from the farmer a certification attesting that he/she redeemed the voucher. Also, we instructed the Auxiliary Market Director to review all the farmer files to ensure they are completed and signed by the farmer and an Agency representative.

View Audit 8540

Finding 6605 (2022-001)

Significant Deficiency 2022

Agricultural Enterprises Development Administration

PR

Reporting Significant Deficiency

Documentation to perform a Single Audit of Stat FY 2023 which ended June 30, 2023 is already submitted to the auditors. They are working on control tests of the data submitted and expect to finish the Single Audit Report on March 31, 2024.

View Audit 8540

Finding 6598 (2022-003)

Significant Deficiency 2022

Sheboygan Senior Community, Inc.

WI

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management will open a separate account and deposit the required funds as required by the loan resolutions.

View Audit 8533

Finding 6577 (2022-001)

Significant Deficiency 2022

City of Biloxi

MS

The City strives to comply with governing rules and regulations. The current year audit was delayed due to the late issuance of the prior year audit as well as the implementation of new accounting standard GASB 87 - Leases. The City continues their efforts to improve processes and have a routine a...

The City strives to comply with governing rules and regulations. The current year audit was delayed due to the late issuance of the prior year audit as well as the implementation of new accounting standard GASB 87 - Leases. The City continues their efforts to improve processes and have a routine audit schedule beginning with fiscal year 2023.

View Audit 8523

Finding 6575 (2023-002)

Significant Deficiency 2022

Wind River Development Fund

WY

Reporting Internal Control / Segregation of Duties

WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In addition, WRDF will utilize QuickBooks to track each grant, d~velop workflows to ensure that all deadlines are met, monitor its performance, and provide regular updates to its Board of Directors...

WRDF will develop a new system for monitoring and tracking grant reporting requirements and deadlines. In addition, WRDF will utilize QuickBooks to track each grant, d~velop workflows to ensure that all deadlines are met, monitor its performance, and provide regular updates to its Board of Directors.

View Audit 8520

Finding 6534 (2022-004)

Material Weakness 2022

Tuscarawas County

OH

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking

TCJFS is already working with Richard Johnson from the OFMS-Bureau of County Finance & Technical Assistance to correct this issue. TCJFS is already restricting draws to get the cash on hand under 10 days. The TCJFS will be using tools and reports to assist in keeping the cash on hand in compliance.

View Audit 8489

Finding 6533 (2022-003)

Material Weakness 2022

Tuscarawas County

OH

Procurement, Suspension & Debarment

In September 2022, County Commissioners approved a revised Procurement Policy which requires departments to verify that vendors for Federally funded projects are not suspended or debarred. The procedure to verify this includes a search of the SAM website. The policy also requires for departments t...

In September 2022, County Commissioners approved a revised Procurement Policy which requires departments to verify that vendors for Federally funded projects are not suspended or debarred. The procedure to verify this includes a search of the SAM website. The policy also requires for departments to screen print the search and include it with bid documentation. The project identified was bid prior to the adoption of the revised Procurement Policy. It is also noted the vendor awarded this project was not suspended or debarred and SAM information was verified prior to any Federal monies being disbursed.

View Audit 8489

Finding 6499 (2022-005)

Significant Deficiency 2022

Palo Alto County Hospital

IA

Reporting Significant Deficiency

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifyin...

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure/use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Health System implemented a formal grant management policy in November 2022. Name(s) of the contact person(s) responsible for corrective action: Collette Johnson, CFO Planned completion date for corrective action plan: November 1, 2022

View Audit 8469

Finding 6498 (2022-004)

Significant Deficiency 2022

Palo Alto County Hospital

IA

Procurement, Suspension & Debarment

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifyin...

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure or use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Health System implemented a formal grant management policy in November 2022. Name(s) of the contact person(s) responsible for corrective action: Collette Johnson, CFO Planned completion date for corrective action plan: November 1, 2022

View Audit 8469

Finding 6497 (2022-003)

Material Weakness 2022

Palo Alto County Hospital

IA

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifyin...

Rural Communities Opioid Response Program – Medication Assisted Treatment (MAT) Expansion – Assistance Listing No. 93.912 Recommendation: We recommend that management implement more formal control process surrounding the use of federal awards where there is segregation between individuals identifying or proposing expenditures/uses of funds and an individual reviewing and approving that expenditure/use. We also recommend for any formal reporting required under federal awards that there be a formal review process where an individual is reviewing and approving the report who did not prepare the report. Documentation of review and approval should be retained in both cases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Health System implemented a formal grant management policy in November 2022. Name(s) of the contact person(s) responsible for corrective action: Collette Johnson, CFO Planned completion date for corrective action plan: November 1, 2022

View Audit 8469

Finding 6496 (2022-002)

Significant Deficiency 2022

Ballet Hawaii

HI

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303

Corrective actions: i. Documented approval of expenditures 1. Approval of expenditures will be documented and retained. 2. Responsible individuals: Kenny Lee (Treasurer), Shaina Gonsalves (Office Manager) 3. Anticipated completion date: June 30, 2024

View Audit 8468

Corrective Action Plans

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