Finding 33542 (2022-001)

Significant Deficiency
Requirement
N
Questioned Costs
-
Year
2022
Accepted
2023-09-20

AI Summary

  • Core Issue: The Healing Lodge is missing key employee documentation, including drug screenings and background checks, which is essential for compliance with DHHS requirements.
  • Impacted Requirements: Internal controls related to employee hiring processes are not being followed, leading to a significant deficiency in compliance.
  • Recommended Follow-Up: Management should implement a system to ensure all required documentation is collected and retained to meet federal guidelines.

Finding Text

Program Information: U.S. Department of Health and Human Services Regional Youth Primary Residential Treatment Program/COVID-19 Cares Test Related Activities/COVID-19 Cares Telehealth/COVID-19 ARPA Related Funding? AL #93.441 Award Number: 248-96-0020 Award Period: 1/1/2021 ? 12/31/2022 Criteria: ?Internal control is a process, effected by an entity?s?[governing body], management, and other personnel, designed to provide reasonable assurance regarding the achievement of objectives in the following categories related to operations, reporting, and compliance. (Internal Control ? Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, May 2013, p.1)? The Healing Lodge requires applicants to pass a drug screen and background investigation before any offer of employment as required by DHHS. Condition/Context: [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness During testing, the following was noted to not be included in employee file or provided by client: ? Checklist for Employee File form for 5 out of 12 samples. ? Personnel Action Notices for 3 out of 12 samples. ? Drug Screenings for 2 out of 12 samples. ? Background checks for 4 out of 12 samples. Cause: The Healing Lodge had turnover in key personnel, as well as lack of management oversight to ensure all information is documented and retained. Effect: Without obtaining and retaining all information for the special test requirements, the Healing Lodge may be out of compliance with federal guidelines. Questioned Costs: Not applicable. Repeat Finding: No. Recommendation: We recommend that management ensure that all documentation is obtained and properly retained to ensure all the proper documentation was received and verified. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.

Corrective Action Plan

Person responsible for the corrective action: Rachel Pelkey, SHRM-CP, Human Resources Director The Healing Lodge of the Seven Nations 5600 E. 8th Ave. Spokane Valley, WA. 99212 Email: rachelp@healinglodge.org Phone: 509.795.8368 Condition: During testing, the following was noted to not be included in employee file or provided by client: Checklist for Employee File form for 5 out of 12 samples. Personnel Action Notices for 3 out of 12 samples. Drug Screenings for 2 out of 12 samples. Background checks for 4 out of 12 samples. Corrective Action: The Healing Lodge has experienced turnover throughout its organization including the Human Resources Department. During 2022 the Healing Lodge had problems with keeping the Human Resources department properly staffed, and such, the various filing requirements had not been met. The Healing Lodge is currently staffed with two Human Resources Professionals who are both well qualified. The Healing Lodge Compliance Officer did an internal audit of the files prior to the financial audit during a transition of one HR manager to another HR Director. It has taken time with the turnover to follow up on the findings of the internal audit and they are currently working on the corrections. In addition, to remain in compliance, the Healing Lodge?s Compliance Team will be doing quarterly Human Resources File Compliance testing to ensure that the files are kept in compliance at all times. Anticipated date of completion: September 18, 2023

Categories

Internal Control / Segregation of Duties Material Weakness Reporting Significant Deficiency

Other Findings in this Audit

  • 33543 2022-001
    Significant Deficiency
  • 33544 2022-001
    Significant Deficiency
  • 33545 2022-001
    Significant Deficiency
  • 609984 2022-001
    Significant Deficiency
  • 609985 2022-001
    Significant Deficiency
  • 609986 2022-001
    Significant Deficiency
  • 609987 2022-001
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.441 Regional Youth Primary Residential Treatment Program $3.26M
93.441 Covid-19 Arpa Related Funding $1.16M
93.933 The Healing Lodge of the Seven Nations Yrtc Aftercare Program $740,631
93.859 Building Cultures of Recovery in Tribal Communities $336,761
93.441 Covid-19 Cares Test Related Activities $94,332
93.859 Assessing Cultures of Recovery in Tribal Communities $87,379
93.441 Covid-19 Cares Telehealth $22,381
10.553 Child and Nutrition Program $16,667