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Corrective Action Plans

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Finding 574609 (2023-003)
Material Weakness 2023
Van Bibber Lake Conservancy District
IN
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303
FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We...
FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Federal funding for the project was fully spent in 2024. In the future, reports required for federal awards will be prepared by the Financial Clerk and reviewed and approved by the District Board or a District Board member. Anticipated Completion Date: August 1, 2025 INDIANA
View Audit 364873
Finding 574594 (2023-004)
Material Weakness 2023
West Hancock Community School District
IA
SEE RESPONSE AND CORRECTIVE ACTION PLAN 2022-001
SEE RESPONSE AND CORRECTIVE ACTION PLAN 2022-001
View Audit 364847
Finding 574592 (2023-005)
Significant Deficiency 2023
Southwest Regional Development Commission
MN
Reporting Internal Control / Segregation of Duties Significant Deficiency
Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective ...
Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective Action Plan: Management has reviewed the findings and taken steps in developing an internal control review process. The Commission implemented procedures to ensure all reports have proof of review and submission, as well as working towards submitting all reports timely. Anticipated Completion Date: June 2026
View Audit 364840
Finding 574586 (2023-004)
Material Weakness 2023
Bristol Bay Borough, Alaska
AK
Subrecipient Monitoring Material Weakness Reporting
Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are pro...
Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2025
View Audit 364808
Finding 574585 (2023-003)
Significant Deficiency 2023
Bristol Bay Borough, Alaska
AK
Period of Performance Allowable Costs / Cost Principles Reporting § 200.512
Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging addition...
Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging additional stakeholders to expedite the completion of future financial reports. Completion Date: September 30, 2025
View Audit 364808
Finding 574582 (2023-006)
Material Weakness 2023
Northshore University Healthsystem
IL
Reporting § 200.303 § 200.502 § 200.510
Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants managemen...
Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants management team, and implementing new policy and procedures for SEFA reporting. Finance and grants management staff will jointly review all grant activity at year-end to ensure proper inclusion in SEFA. Management acknowledges the importance of accurate SEFA reporting and is committed to strengthening internal controls to prevent similar issues in future reporting periods. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health
View Audit 364802
Finding 574543 (2023-003)
Material Weakness 2023
Northshore University Healthsystem
IL
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...
Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office
View Audit 364802 Questioned Costs: $1
Finding 574510 (2023-004)
Material Weakness 2023
Northshore University Healthsystem
IL
Questioned Costs Subrecipient Monitoring
Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment an...
Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment and monitoring that are in place from the Research department. We will leverage key resources within the organization to address areas of noncompliance. Responsible Official: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE
View Audit 364802 Questioned Costs: $1
Finding 574488 (2023-005)
Significant Deficiency 2023
Northshore University Healthsystem
IL
Allowable Costs / Cost Principles
Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved...
Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved rate prospectively. Accounting will assess the variance between the new approved rate and the prior rate used. Research will approve the adjustment based on materiality and document the adjustment process. Management will develop a policy around the fringe allocation and adjustment Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office and Annaliza Villamin, System Director of Accounting, Endeavor Health
View Audit 364802
Finding 574484 (2023-002)
Material Weakness 2023
Northshore University Healthsystem
IL
Allowable Costs / Cost Principles Reporting
Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...
Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office
View Audit 364802
Finding 574483 (2023-001)
Material Weakness 2023
Northshore University Healthsystem
IL
Reporting § 200.303 § 200.502 § 200.510
Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconcil...
Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health
View Audit 364802
Finding 574457 (2023-003)
Material Weakness 2023
Pinecrest Medical Care Facility
MI
Material Weakness Reporting Matching / Level of Effort / Earmarking
Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review p...
Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review process in place for the required submissions. Planned Corrective Action: Management agrees with the finding and will implement a process to ensure an independent review of the reporting submission and its supporting documents is completed prior to finalization. Contact person responsible for corrective action: Brooke Ponchaud, Chief Financial Officer Anticipated Completion Date: 05/01/2024
View Audit 364788
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
Corrective Actions Taken:
Corrective Actions Taken:
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
1. A revised SFDP policy aligned with HRSA compliance standards was approved by the Board in early 2024 and implemented across all sites.
1. A revised SFDP policy aligned with HRSA compliance standards was approved by the Board in early 2024 and implemented across all sites.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
2. Eligibility documentation procedures were updated: staff now document income and family size at intake, visually mark the applicable discount level on the SFDP form, and enter discount data into the patient’s EHR.
2. Eligibility documentation procedures were updated: staff now document income and family size at intake, visually mark the applicable discount level on the SFDP form, and enter discount data into the patient’s EHR.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
3. Clinic signage and intake materials were revised to ensure all patients are informed of the SFDP at the point of service.
3. Clinic signage and intake materials were revised to ensure all patients are informed of the SFDP at the point of service.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
4. Intake and billing staff received training on SFDP eligibility, documentation, and communication protocols in 2024, with annual refreshers planned.
4. Intake and billing staff received training on SFDP eligibility, documentation, and communication protocols in 2024, with annual refreshers planned.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
5. In February 2025, SCMRC transitioned to a new revenue cycle management (RCM) vendor, improving accuracy in SFDP patient setup and billing workflows.
5. In February 2025, SCMRC transitioned to a new revenue cycle management (RCM) vendor, improving accuracy in SFDP patient setup and billing workflows.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
6. Monthly CQI chart audits now include a review of SFDP documentation and eligibility determinations to monitor compliance.
6. Monthly CQI chart audits now include a review of SFDP documentation and eligibility determinations to monitor compliance.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
Corrective Action Plan:
Corrective Action Plan:
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
1. Maintain annual training on SFDP policies and documentation for all intake and billing staff.
1. Maintain annual training on SFDP policies and documentation for all intake and billing staff.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
2. Continue including SFDP compliance checks in monthly CQI chart audits.
2. Continue including SFDP compliance checks in monthly CQI chart audits.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
3. Conduct annual reviews of SFDP utilization trends, fee schedule accuracy, and patient communication practices.
3. Conduct annual reviews of SFDP utilization trends, fee schedule accuracy, and patient communication practices.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
4. Include SFDP updates in Compliance Committee reports, with findings presented annually to the Board.
4. Include SFDP updates in Compliance Committee reports, with findings presented annually to the Board.
View Audit 364765
Finding 574310 (2023-016)
Material Weakness 2023
South Central Medical and Resource Center, Inc.
OK
5. Continue coordination between front desk, billing, and RCM teams to ensure proper EHR setup for all SFDP patients.
5. Continue coordination between front desk, billing, and RCM teams to ensure proper EHR setup for all SFDP patients.
View Audit 364765
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