Corrective Action Plans

Finding 20628 (2022-004)

Significant Deficiency 2022

PR

Subrecipient Monitoring Reporting Significant Deficiency

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Acc...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Juan C. Garcia Padilla, Mayor Contact Person: Mrs. Miraisa David Esparra, Finance and Budget Director Phone: (787) 825-1150 Original Finding Number: 2022-004 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: The new Program Director is aware about the compliance requirement. We gave instructions to the Program Director to maintain a dateline control sheet to ascertain that required reports were submitted within the due date. Implementation Date: April 30, 2023 Responsible Person: Mr. Hector R. Sanjurjo Rodriguez Federal Programs Director See Corrective Action Plan for chart/table

View Audit 27451

Finding 20627 (2022-003)

Significant Deficiency 2022

Municipality of Coamo

PR

Equipment & Real Property Management Questioned Costs Significant Deficiency

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Acc...

COMMONWEALTH OF PUERTO RICO MUNICIPALITY OF COAMO Corrective Action Plan For the Fiscal Year Ended June 30, 2022 _____________________________________________________________________________________________________________________ Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2021 ? June 30, 2022 Fiscal Year: 2021-2022 Principal Executive: Hon. Juan C. Garcia Padilla, Mayor Contact Person: Mrs. Miraisa David Esparra, Finance and Budget Director Phone: (787) 825-1150 Original Finding Number: 2022-003 Corrective Action Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: During the fiscal year 2021-2022 the Community Development Block Grants/State?s Program administered by the Municipality of Coamo expended $360,628. Of such total expended, $132,062 were related to capital expenditures; $21,749 for the installation of an elevator in a building whose construction is in progress, and $110,313 for municipal streets paving as specified in the approved proposal. But, as expressed in the corrective action related to Finding 2022-002, we are going to identify budgetary resources to engage another staff to work with the capital assets subsidiary ledger completeness. Implementation Date: During the Fiscal Year 2023-2024 Responsible Person: Mrs. Miraisa David Esparra Finance Department Director See Corrective Action Plan for chart/table

View Audit 27451

Finding 20622 (2022-001)

Material Weakness 2022

Butler County Community College

PA

Questioned Costs Reporting

The College concurs with Finding 2022-001 by our audit firm. In response to that finding the College has reviewed and accepted the recommendation by our audit firm as of December 1, 2022. As of September 2022, Butler County Community College has completed necessary programming changes to compile req...

The College concurs with Finding 2022-001 by our audit firm. In response to that finding the College has reviewed and accepted the recommendation by our audit firm as of December 1, 2022. As of September 2022, Butler County Community College has completed necessary programming changes to compile required reporting data for required reports. The most recent quarterly report as required by 2 CFR Part 200 was completed and it is posted prominently on our website. The College also has plans to complete spending of funds from the Education Stabilization fund prior to December 31, 2022 and will submit the final Annual report on time and close out this grant. The Controller for the College, Wm. Jake Friel, will be responsible for the compliance and along with Finance Office staff will complete the required reports and submit the reports to the website manager to post on the agreed website page.

View Audit 26584

Finding 20621 (2022-001)

Significant Deficiency 2022

Stoughton Area School District

WI

Special Tests & Provisions Eligibility Reporting

Reference Number: 2022-001 Description: Medicaid Bus Logs Corrective Action Plan: The District will ensure that information from the bus logs is accurately included in the data used to calculate the transportation ratio. Anticipated Corrective Action Plan Completion Date: January 2023 Contact In...

Reference Number: 2022-001 Description: Medicaid Bus Logs Corrective Action Plan: The District will ensure that information from the bus logs is accurately included in the data used to calculate the transportation ratio. Anticipated Corrective Action Plan Completion Date: January 2023 Contact Information: For additional information regarding this finding please contact Erica Pickett, Director of Business Services, at 608-877-5011.

View Audit 24296

Finding 20612 (2022-001)

Significant Deficiency 2022

Town of Prescott Valley, Arizona

AZ

Procurement, Suspension & Debarment

Findings and Questioned Costs Related to Federal Awards Finding Number: 2022-001 Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Katie Pehl, Finance Director Anticipated Completion Date: Septemb...

Findings and Questioned Costs Related to Federal Awards Finding Number: 2022-001 Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Katie Pehl, Finance Director Anticipated Completion Date: September 22, 2022 Planned Corrective Action: Town of Prescott Valley implemented a procedure to verify suspension and debarment for all vendors with whom the Town is planning to spend federal grant monies regardless of the amount.

View Audit 21047

Finding 20611 (2022-002)

Material Weakness 2022

Mahalo Homes, Inc.

MD

HUD Housing Programs Questioned Costs Cash Management

Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts compliance requirements. Action Taken: The Organization will pay down the residual receipts note in the amount previously approved by HUD. Otherwise it will appear that th...

Recommendation: Training of staff should be performed to bring staff up to date with the implementation of all residual receipts compliance requirements. Action Taken: The Organization will pay down the residual receipts note in the amount previously approved by HUD. Otherwise it will appear that they are holding excess residual receipts, which is not the case.

View Audit 20879 Questioned Costs: $1

Finding 20610 (2022-001)

Material Weakness 2022

Mahalo Homes, Inc.

MD

Questioned Costs HUD Housing Programs Reporting

Recommendation: In conjunction with Mahalo Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Mahalo Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The a...

Recommendation: In conjunction with Mahalo Homes, Inc. and their local HUD field office, it was determined that the related party should invoice the Organization for project expenses on a monthly basis. In turn, Mahalo Homes, Inc. should pay the invoice amount on a monthly basis. Action Taken: The auditors have worked with the auditee to determine a course of action. All parties agreed with the recommendation to avoid unauthorized distributions.

View Audit 20879 Questioned Costs: $1

Finding 20609 (2022-002)

None 2022

Robeson County Housing Authority

NC

Questioned Costs HUD Housing Programs

2022-002: The files in question will be adjusted during the tenant?s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. The internal audit team will conduct intern...

2022-002: The files in question will be adjusted during the tenant?s annual recertification. The housing managers (along with internal audit team members) will attend yearly rent recalculation refresher courses and check for errors when recalculating rent. The internal audit team will conduct internal tenant file reviews monthly. The Housing Director will discuss file management during monthly staff meetings. The Authority plans to implement these procedures effective January 1, 2023.

View Audit 19320 Questioned Costs: $1

Finding 20608 (2022-001)

None 2022

Robeson County Housing Authority

NC

HUD Housing Programs

2022-001: In the original budget, funds were budgeted for debt service. In May 2022, the Authority approved a budget revision that mistakenly reallocated the debt service budget dollars. This debt was paid off in August 2022. We do not anticipate this to be a finding in the next fiscal year.

View Audit 19320

Finding 20598 (2022-002)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement wi...

Head Start ? Assistance Listing No. 93.600 Recommendation: Alliance for Community Empowerment, Inc. should formalize review over employee coding and allocations to ensure that allocations are based on actual time and effort. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The entry of all department coding will be reviewed by the Payment Coordinator by running a new hire report to ensure all new and returning employees are allocated to the proper department code. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 04/24/2023 If the Department of Health and Human Services has questions regarding this plan, please call Indi Hayes at 475.476.7440.

View Audit 20358 Questioned Costs: $1

Finding 20597 (2022-001)

Significant Deficiency 2022

Alliance for Community Empowerment, Inc.

CT

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are ...

Head Start ? Assistance Listing No. 93.600 Community Services Block Grant ? Assistance Listing No. 93.569 Recommendation: We recommend Alliance for Community Empowerment, Inc. design controls to ensure an adequate review process is in place to review the period of costs incurred to ensure costs are charged to grants in the proper period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All expenditures will be reviewed and recorded in the proper period of performance. The correction was put into place during the audit and all expenditures have been reviewed during entry and at the point of signature from the Finance Director. Name of the contact person responsible for corrective action: Indi Hayes Planned completion date for corrective action plan: 4/24/2023

View Audit 20358 Questioned Costs: $1

Finding 20585 (2022-001)

Material Weakness 2022

Verona R-Vii School District

MO

Internal Control / Segregation of Duties HUD Housing Programs

CORRECTIVE ACTION PLAN October 4, 2022 U.S. DEPARTMENT OF EDUCATION Verona School District R-VII respectfully submits the following corrective action plan for the year ended June 30, 2022. Contact information for the individual responsible for the corrective action: Dr. Tony Simmons, Superintend...

CORRECTIVE ACTION PLAN October 4, 2022 U.S. DEPARTMENT OF EDUCATION Verona School District R-VII respectfully submits the following corrective action plan for the year ended June 30, 2022. Contact information for the individual responsible for the corrective action: Dr. Tony Simmons, Superintendent Verona School District R-VII 101 E Ella Street Verona, MO 65734 (417) 498-2274 Independent Public Accounting Firm: The CPA Group, PC, 217 4th Street, Monett, MO 65708 Audit Period: Year ended 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. FINDINGS ? FINANCIAL STATEMENT AUDIT Material Weakness ? Internal Control over Financial Reporting - Segregation of duties Finding 2022-001 Recommendation: We realize Because of limited resources and personnel, management may not be able to achieve a proper segregation of duties; however, our professional standards require that we bring this lack of segregation of duties to your attention in this report. Action Taken: The limited number of available personnel prohibits segregation of incompatible duties and the District does not have the resources to hire additional accounting personnel. Completion Date: Not applicable Sincerely, Dr. Tony Simmons, Superintendent Verona School District R-VII

View Audit 20357

Finding 20583 (2022-002)

None 2022

Tuskegee University

AL

Questioned Costs Allowable Costs / Cost Principles § 200.430

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the...

Finding 2022-002 ? Allowable Cost/ Cost Principles Planned Corrective Action: In November 2022, the University removed all unallowable salary and related fringe benefits costs off the affected grants, returned funds to USDA through the ASAP drawdown process, and corrected the SEFA. Additionally, the Office of Human Resources (HR) and Office of Grants and Contracts (OGCA) have implemented and strengthen monthly review procedures for Personnel Action Forms. In January 2023, Human Resources granted the OGCA query and view access to the Person?s Pay Distribution Module for employees working on grants and contracts. This will allow the OGCA staff to compare the PAFs to HR and Payroll data and identify errors, if any, for correction. Upon receipt of PAFs in the OGCA, the following steps will occur: A. (1) Verify that the faculty and or staff can be specifically identified with the sponsored project; (2) Verified the position in the budget and/or have the prior written approval of the funding agency; (3) Compare the grant period to the personnel action form (PAF) start and end date; and (4) ensure that required approved signatures (Principal Investigator, Department Head and/or Dean) are present. C. Once the above conditions have been met, the Financial Analyst signs the PAF, forward to the Budget Officer and the VP for Business Affairs/CFO, for approval. The approved document is then submitted to the Office of the President and finally, Human Resources for review, approval, and compliance with university employment guidelines and policies. Once approved, HR enters the PAF into the Colleague System. An employment contract is generated as applicable. D. Monthly Review of the Grants General Ledger Summary Report (GLSA) and the General Ledger Trial Balance (GLTB) and or General Ledger Budget Status (GLBS) are completed by the Grants Financial Analysts. This monthly review is to verify that amounts charged are allowable and accurately posted to the correct departmental account and object codes. Payroll charges are compared to the PAFs. E. The OGCA, HR, and Payroll Offices collaborate on any discrepancies or errors and resolve immediately. Anticipated Date of Completion: Corrective action completed as of the date of this report. Person Responsible for Corrective Action Plan: Mr. Dexter Odom, Chief Financial Officer

View Audit 20254 Questioned Costs: $1

Finding 20569 (2022-001)

Material Weakness 2022

Icahn School of Medicine at Mount Sinai

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs § 200.303

Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described ab...

Finding 2022-001 Special Tests and Provisions Information on the federal program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: Management agrees with the finding described above. The ISMMS Office of Student Financial Services has implemented a combined monthly reconciliation and drawdown process that identifies and resolves discrepancies, as required by the U.S. Department of Education?s Direct Loan reconciliation guidelines under 34 CFR 685.300(b)(5). The process will be detailed in the School?s procedure manual and staff will be trained accordingly. With this new process in place, we will be compliant with the U.S. Department of Education regulations. Name of responsible official: LaVerne Walker Director of Student Financial Services laverne.walker@mssm.edu Projected completion date: ? September 26, 2023: Completed implementation of combined monthly reconciliation and drawdown process ? December 31, 2023: Completed staff training sessions and revision to procedure manual

View Audit 28674

Finding 20566 (2022-001)

Significant Deficiency 2022

Johnnie B. Moore Towers, Inc.

GA

Questioned Costs HUD Housing Programs

Reportable Views of Responsible Officials: We agree that the Corporation overpaid the management fees, resulting in a receivable from HRC as of December 31, 2022. Management agrees that the fees were paid in excess of the amount allowed by the HUD approved management certification. Context: Not appl...

Reportable Views of Responsible Officials: We agree that the Corporation overpaid the management fees, resulting in a receivable from HRC as of December 31, 2022. Management agrees that the fees were paid in excess of the amount allowed by the HUD approved management certification. Context: Not applicable Recommendation: Management fee calculations should be consistent with terms agreed upon. Auditors? Summary of the Auditee?s Comments on the Findings and Recommendations: Agree with management's assessment. Response Indicator: Agree Completion Date: 12/31/2023

View Audit 28353 Questioned Costs: $1

Finding 20565 (2022-001)

Material Weakness 2022

Decatur Hospital Authority D/b/a Wise Health System and Affiliates

TX

Allowable Costs / Cost Principles Questioned Costs Reporting

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s...

Corrective Action Plan for Finding 2022-001 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding questioned costs and material instance of noncompliance with respect to Activities Allowed/Unallowed and Allowable Costs/Cost Principles. Decatur Hospital Authority?s Chief Financial Officer, Todd Scroggins, is responsible to oversee and implement the corrective action plan. In its Provider Relief period three and period four reporting submissions for the year ended December 31, 2022, the Authority?s reports included the activity of the Authority and their Nursing Home Facilities (Nursing Homes). The reported activity included other PRF expenses, nursing home infection control expenses and lost revenues. There are four separate nursing home management companies that provide services to the Authority?s seven Nursing Homes. There were approximately $358,571 in nursing home infection control expenses that were unable to be reconciled to eligible expenses for one of the Nursing Homes. The Authority provided the Nursing Homes with templates to use to provide the Authority with the necessary information for the reporting as the reporting was complete on the TIN of the Authority. The Authority relied on the accuracy of the information provided by the Nursing Homes. The Authority was not aware of the findings in the audit of period 1 and period 2 at the time the Authority submitted period 3 reporting. Therefore, the inaccurate reconciliation of eligible infection control expenses from period 2 was also used for reporting in period 3, which caused a recurrence in audit findings due to timing of audits and findings reported to the Authority. The Authority?s CFO will judgmentally perform detailed testing of reported costs and lost revenue from the Nursing homes in future reporting periods. In addition, the Authority?s CFO and management team will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Authority will modify the policies and procedures over federal grant reporting. The Authority?s CFO will oversee this to ensure that it is accomplished for future unreported periods as of this date. The corrective action plan will be implemented by December 31, 2023.

View Audit 27070 Questioned Costs: $1

Finding 20564 (2022-002)

Significant Deficiency 2022

Battle Creek Housing Commission

MI

HUD Housing Programs Questioned Costs Reporting

2022-002 Housing Choice Vouchers ? CFDA 14.871 Recommendation: The Commission should implement policies and procedures to ensure all proper reporting is completed per the grant requirements. Action Taken: Management will implement policies and procedures to ensure compliance with all reporting r...

2022-002 Housing Choice Vouchers ? CFDA 14.871 Recommendation: The Commission should implement policies and procedures to ensure all proper reporting is completed per the grant requirements. Action Taken: Management will implement policies and procedures to ensure compliance with all reporting requirements of the Housing Choice Voucher Grant. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661

Finding 20563 (2022-003)

Significant Deficiency 2022

Battle Creek Housing Commission

MI

Procurement, Suspension & Debarment § 200.317

2022-003 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the...

2022-003 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to Procurement, Suspension and Debarment. Action Taken: Management will implement policies and procedures to ensure the Commission is in compliance with all grant requirements pertaining to the Public and Indian Housing Grant. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661

Finding 20562 (2022-001)

Material Weakness 2022

Battle Creek Housing Commission

MI

Questioned Costs Subrecipient Monitoring Material Weakness

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies a...

Compliance with Laws and Regulations (Material Weakness) 2022-001 Public and Indian Housing ? CFDA 14.850 Recommendation: The Commission should require its financial institutions to provide documentation of collateral at a minimum on a quarterly basis. The Commission should also adopt policies and procedures to monitor its cash and investments continuously to verify that the collateral provided by the financial institutions is adequate throughout the year. Action Taken: Management will implement a new process that will require the banks to provide proof of insurance coverage on a quarterly basis, at minimum. Anticipated Completion Date of Action: September 30, 2023

View Audit 26661 Questioned Costs: $1

Finding 20560 (2022-001)

Material Weakness 2022

The St. Luke's-Roosevelt Hospital Center and Affiliates

NY

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program ...

Current Year Audit Findings and Corrective Action Plan For the Year Ended December 31, 2022 Finding 2022-001 ? Eligibility Internal control deficiency over the reassessment requirement to determine eligibility Identification of the federal program: Assistance Listing Number 93.914 ? Program Name: HIV Emergency Relief Project Grants ? Grantor: Department of Health and Human Services (HHS) ? Federal award identification number: Not Applicable Views of responsible officials and planned corrective actions: Management agrees with the finding. Management will develop internal controls to implement effective internal controls regarding 1) Review and retention of income and residency verification at program Intakes, and 2) Real time documentation of participants? income and residency eligibility at the required frequency (typically during 6 month Reassessments) with accepted supporting documentation for each participant. 3) This documentation will be entered into our EMR (EPIC) for each patient, outlining our eligibility verifications done at Intakes, Reassessments or Reassessment Attempts, along with screen shots from ePACES and/or other eligibility documents used. This will enable our program team and our funders and auditors to be able to more easily review our documented ongoing program eligibility for each patient. This will also improve our quality controls and will enable program staff to more effectively monitor annual eligibility checks. Contact person: Diane Tider Expected Completion Date: Implementing immediately 10/2/23

View Audit 26659

Finding 20557 (2022-003)

Material Weakness 2022

Albany Leadership Charter School for Girls

NY

Reporting

Name of Auditee: Albany Leadership Charter School for Girls Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2022 CAP Prepared by: Carina Cook, Superintendent Phone: 518-694-5300 Current Finding on the Schedule of Findings and Responses 3) Finding 2022-003...

Name of Auditee: Albany Leadership Charter School for Girls Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2022 CAP Prepared by: Carina Cook, Superintendent Phone: 518-694-5300 Current Finding on the Schedule of Findings and Responses 3) Finding 2022-003 - The Data Collection Form for the year ended June 30, 2022 was not filed with the Federal Audit Clearinghouse within nine months after year end. a. Implementation of Plan of Action - Management will work with the auditors for timely completion of the audit and filing of the Data Collection Form. b. Implementation Date - Management expects to have this completed March 31, 2024. c. Persons Responsible for the Implementation - The Board of Trustees and the Superintendent.

View Audit 26325

Finding 20556 (2022-002)

Material Weakness 2022

Albany Leadership Charter School for Girls

NY

Name of Auditee: Albany Leadership Charter School for Girls Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2022 CAP Prepared by: Carina Cook, Superintendent Phone: 518-694-5300 Current Finding on the Schedule of Findings and Responses 2) Finding 2022-002...

Name of Auditee: Albany Leadership Charter School for Girls Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2022 CAP Prepared by: Carina Cook, Superintendent Phone: 518-694-5300 Current Finding on the Schedule of Findings and Responses 2) Finding 2022-002 - Salary contracts for two employees could not be obtained and reviewed for approval. a. Implementation of Plan of Action - Management will begin keeping signed copies of employee salary contracts in the employee?s personnel file. b. Implementation Date - The School expects to have this completed by June 30, 2024. c. Persons Responsible for the Implementation - The Board of Trustees and the Superintendent.

View Audit 26325

Finding 20555 (2022-001)

Significant Deficiency 2022

McLean County, Illinois

IL

Procurement, Suspension & Debarment § 200.318

The County?s Procurement Policy is being updated to include a Federal Procurement Checklist to be used for purchases using Federal funds.

View Audit 24118

Finding 20553 (2022-001)

Material Weakness 2022

Southwest Montana Community Health Center

MT

2022-001: Material Weakness - Application of Sliding Fee Schedule Discount Contact Person: Shelly Davis, CFO Criteria: The Community Health Center is required to have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and d...

2022-001: Material Weakness - Application of Sliding Fee Schedule Discount Contact Person: Shelly Davis, CFO Criteria: The Community Health Center is required to have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover the reasonable costs of operation. The corresponding sliding fee schedule of discounts applied and adjusted should be based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services. Condition: During our testing of the sliding fee schedule, we noted the Community Health Center has a sliding fee schedule, whereby the basis of the patient?s ability to pay is based upon the patient?s income, using the federal poverty guidelines as a basis for the percentage of the sliding fee schedule discount. However, in three of the forty patient files tested, the sliding fee schedule discount was calculated incorrectly causing the sliding fee schedule discount to be improperly applied. Cause: The Community Health Center is not following policies and procedures set in place to ensure the sliding fee schedule discount is correctly determined and applied to patient accounts. Effect: The sliding fee discount applied is incorrect. Indication of Repeat Finding: This is a repeat finding. The finding in the prior audit was 2021-001. Recommendation We recommend the Community Health Center?s sliding fee schedule discount be correctly applied by following established policies and procedures regarding the sliding fee schedule calculation. Views of Responsible Officials and Planned Corrective Actions: The Community Health Center has been focused on continuous improvement and ongoing focused training for the past two years. The Clinic has continued to implement new workflows and procedures. In January 2022, we started to internally review 100% of the sliding fee documents and correct any errors as soon as they are discovered. Additionally, our Billing department does a review of a random sample to ensure our internal audit is performing as planned. Our organization?s leadership and Board of Directors understand the importance of the requirement to apply our policies and procedures accurately and appropriately regarding the sliding fee discount calculations. The Community Health Center has taken swift and direct actions to improve our adherence to our policies and procedures related to the sliding fee discounts. Corrective Action Plan 1. Stakeholders and supervisors meet weekly to report errors made, confirm corrections completed, note trainings performed, and identify potential weaknesses and plan for improved workflows. 2. Internally review 100% of the sliding fee calculations in a prompt manner. 3. Make corrections to all identified errors immediately. 4. Billing supervisor will review monthly, a sampling of all sliding fee calculations from the prior month, as an additional measure to identify any miscalculations. 5. Hourly wage rates of patient support staff have been increased to improve the hiring and retaining of qualified staff in these vital roles that work with the patient and the sliding fee discount. 6. Focused individual and group trainings with patient support staff is scheduled monthly or more often if needed. 7. Intense training of new employees is completed promptly upon hiring. 8. Establish staff reward system for reduction of sliding fee discount calculation errors. 9. Outstanding performance by patient support staff, reflected as no errors, will see increased wages at annual reviews.

View Audit 22434

Finding 20550 (2022-002)

Significant Deficiency 2022

Salud Family Health

CO

Questioned Costs

Recommendation: Out auditors recommended the Corporation take measures to ensure that appropriate sliding fee rates/categories are used for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding...

Recommendation: Out auditors recommended the Corporation take measures to ensure that appropriate sliding fee rates/categories are used for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Corporation utilizes an external billing company. The external billing company has implemented an automated revision using robotics to ensure that sliding fee adjustments are made accurately according to the patients' sliding fee scale. Also, as required by HRSA, the Corporation records household income in our EMR for both sliding fee and non-sliding fee patients. Enrollment specialists process and record household income based on documentation supplied within a sliding fee application. Customer Service Associates record household income based on verbal representations for non-sliding fee patients. The issue involving not having a sliding fee application on file was caused by a Customer Service Associate incorrectly recording a verbal representation as a renewal of a sliding fee application. The Corporation will reinforce to all Customer Service Associates that renewal of sliding fee discounts must be performed by Enrollment Staff so that the income can be verified by documentation. Name(s) of the contact person(s) responsible for corrective action: Dave Madsen, CFO Planned completion date for corrective action plan: Has been implemented.

View Audit 18108

Corrective Action Plans

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