Corrective Action Plans

Finding 915 (2023-001)

Significant Deficiency 2023

MI

Allowable Costs / Cost Principles § 200.402

The Business Manager will review all grant agreements to gain a thorough understanding of allowable costs and then establish and modify or amend grant budgets appropriately to assure that only allowable costs are charged to federal grants. The Superintendent will review all federal budget amendment...

The Business Manager will review all grant agreements to gain a thorough understanding of allowable costs and then establish and modify or amend grant budgets appropriately to assure that only allowable costs are charged to federal grants. The Superintendent will review all federal budget amendments. We will put this into effect immediately going forward in all future grant agreements.

View Audit 1694

Finding 906 (2023-003)

Significant Deficiency 2023

Litchfield Community Unit School District No. 12

IL

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

2023-003 Condition: The District submitted an expenditure to the Illinois State Board of Education in excess of the budget. Recommendation: The District should ensure that the expenditure reports filed with the Illinois State Board of Education are in accordance with the items included in the bu...

2023-003 Condition: The District submitted an expenditure to the Illinois State Board of Education in excess of the budget. Recommendation: The District should ensure that the expenditure reports filed with the Illinois State Board of Education are in accordance with the items included in the budget. Management Response: The District will take the necessary steps to ensure the expenditures fall within the budget line items. If necessary, the District will amend the budget to avoid over expending a line item in the original budget. Anticipated Date of Completion: June 30, 2024

View Audit 1684 Questioned Costs: $1

Finding 898 (2023-001)

Significant Deficiency 2023

Ashley Community Schools

MI

Questioned Costs Allowable Costs / Cost Principles § 200.430

Ashley Community Schools will immediately implement procedures to ensure documentation of distribution of salaries and wages is regularly completed, reviewed, authorized and maintained. The direct supervisor of all staff providing services under federal awards will ensure documentation is compiled, ...

Ashley Community Schools will immediately implement procedures to ensure documentation of distribution of salaries and wages is regularly completed, reviewed, authorized and maintained. The direct supervisor of all staff providing services under federal awards will ensure documentation is compiled, reviewed and authorized no less than quarterly. Original documentation will be maintained by the direct supervisor and copies of fully executed documentation will be shared with the superintendent’s office for storage for a minimum of five years.

View Audit 1663 Questioned Costs: $1

Finding 858 (2023-003)

Significant Deficiency 2023

Westwood Community School District

MI

Allowable Costs / Cost Principles

The District concurs with the finding. The District will implement procedures to ensure compliance requirements of the program.

View Audit 1639

Finding 706 (2023-001)

Significant Deficiency 2023

Bicentennial Apartments, Inc.

WY

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency

Management’s Response: Cable rates paid by tenants were increased recently to help cover more of the costs. We have contacted the carrier for a copy of the current contract, upon receipt we are going to opt out of the contract per the provisions of said contract. When reviewing a different contract ...

Management’s Response: Cable rates paid by tenants were increased recently to help cover more of the costs. We have contacted the carrier for a copy of the current contract, upon receipt we are going to opt out of the contract per the provisions of said contract. When reviewing a different contract (same provider) with another project it states that we will have to give a 90-day notice prior to the expiration of the then-current term. If this is the case, it will be May 20th, 2024, to terminate on July 20th 2024.

View Audit 1355

Finding 687 (2023-001)

Significant Deficiency 2023

Chittenango Central School District

NY

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

During a desktop monitoring review with the New York State Department of Education, the District was made aware of the requirement to maintain the required time certification forms. Steps have been taken to capture all required signatures on payroll charged to the related grants. Projected completio...

During a desktop monitoring review with the New York State Department of Education, the District was made aware of the requirement to maintain the required time certification forms. Steps have been taken to capture all required signatures on payroll charged to the related grants. Projected completion date is estimated to be January 31, 2024.

View Audit 1321

Finding 642 (2023-002)

Significant Deficiency 2023

Moraine Valley Community College District Number 524

IL

Subrecipient Monitoring Cash Management Allowable Costs / Cost Principles § 200.303 § 200.305

Identifying Number: 2023-002 Finding: For one out of two subrecipient payments tested, the College did not submit payment within 30 days after receipt of the billing from the subrecipient. Corrective Action Planned: The College will update its subrecipient invoice payment procedure to establish st...

Identifying Number: 2023-002 Finding: For one out of two subrecipient payments tested, the College did not submit payment within 30 days after receipt of the billing from the subrecipient. Corrective Action Planned: The College will update its subrecipient invoice payment procedure to establish stronger internal controls related to tracking subrecipient invoice approval routing. The College will ask each subrecipient to include the Manager of Grants Accounting and Compliance on any requests for reimbursements. If a subrecipient’s invoice meets Moraine Valley’s criteria for performance and fiscal compliance, the Manager of Grants Accounting and Compliance will monitor the approval process to make sure it is properly approved by the grant’s Principal Investigator, the Director of Resource Development, and the Manager of Grants Accounting and Compliance. This additional monitoring will help ensure all subrecipient invoices are paid within 30 days of receipt. If the invoice does not meet the College’s criteria including all proper supporting documentation, the invoice will be returned to the subrecipient for corrections. Anticipated Completion Date: June 30, 2024 Responsible Person: Darren Howard, Manager of Grants Accounting and Compliance Howardd46@morainevalley.edu

View Audit 1222

Finding 573 (2023-002)

Significant Deficiency 2023

East China School District

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

Management will work with various departments to review current policies and procedures related to federal grant awards. We will focus on the related controls necessary to avoid transactions paid in advance that extend passed the expenditure period. Grant procedures will include review, approval a...

Management will work with various departments to review current policies and procedures related to federal grant awards. We will focus on the related controls necessary to avoid transactions paid in advance that extend passed the expenditure period. Grant procedures will include review, approval and consideration during the grant planning process.

View Audit 1118

Finding 544 (2023-001)

None 2023

Tawas Area Schools

MI

Questioned Costs Allowable Costs / Cost Principles

The District understands the issue and will reclassify the excess expenses charged to the ESSER grant and include/incur other allowable expenses in those charged to the grant.

View Audit 1068 Questioned Costs: $1

Finding 425 (2023-001)

Significant Deficiency 2023

Shands Jacksonville Medical Center, INC

FL

Allowable Costs / Cost Principles Cash Management Eligibility

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi...

Views of responsible officials and planned corrective actions: The Financial and Data Analytics Director conducts spot testing of each bi-weekly payroll expenditure report received from Human Resources for eligible PRF reporting. Evidence of testing is retained. Responsible Officials: Dean C. Cocchi, Vice President and CFO Completion Date: March 31, 2022

View Audit 896

Finding 416 (2023-001)

Significant Deficiency 2023

National Crime Victim Law Institute

OR

Allowable Costs / Cost Principles Significant Deficiency

National Crime Victim Law Institute respectfully submits the following corrective action plan for the year ended May 31, 2023. Contact Person of National Crime Victim Law Institute: Julie Hester, Director of Administration and Operations 1130 SW Morrison Street, Suite 240, Portland, Oregon 97205 N...

National Crime Victim Law Institute respectfully submits the following corrective action plan for the year ended May 31, 2023. Contact Person of National Crime Victim Law Institute: Julie Hester, Director of Administration and Operations 1130 SW Morrison Street, Suite 240, Portland, Oregon 97205 Name and Address of Independent Public Accounting Firm: McDonald Jacobs, P.C. 520 SW Yamhill, Suite 500, Portland, Oregon 97204 Audit Period: June 1, 2022 through May 31, 2023. The finding from the May 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding # 2023-001 Type: Federal award, Significant deficiency regarding allowable costs Finding For three months tested, amounts charged to the grant for allocated rent expenses were inaccurate or did not agree to the accounting records, resulting in insignificant over and under billings. Recommendation: Contract billings should be reconciled to the accounting records and a review of the reconciliation should be completed before invoicing the government agency. Corrective Action: NCVLI has engaged the services of a contract accounting firm for fiscal year 2023-24. This accounting firm will assist with monthly financial transactions, maintaining accounting records and assisting with billings. This firm will work closely with the Director of Administration & Operations (DAO). Among the benefits of this additional layer of support for accounting work is a new process for rent allocations which ensures calculations are reviewed and affirmed by multiple people. Rent allocations are generated by the accounting firm and reviewed by the DAO prior to generation of billings. Billings will then be generated by the DAO with assistance from the accounting firm and will continue to be reviewed and approved by the Executive Director prior to submission to federal agencies. As an additional check, regular internal review of monthly payroll and rent allocations will be conducted by a member of the management team other than the DAO to ensure supporting documentation and reports from accounting system align and support allocations. Anticipated Completion Date: September 2023

View Audit 868

Finding 401 (2023-001)

Significant Deficiency 2023

Community Health Care, Inc.

IA

Allowable Costs / Cost Principles Reporting

CHC agrees it did not allocate its Iowa Medicaid Wrap-Around payments to the Dental and Pediatric Services lines correctly. As the additional context states in the audit report, CHC agrees the departmental allocation did not affect its overall financial statements for the 2020, 2021, and 2022 quart...

CHC agrees it did not allocate its Iowa Medicaid Wrap-Around payments to the Dental and Pediatric Services lines correctly. As the additional context states in the audit report, CHC agrees the departmental allocation did not affect its overall financial statements for the 2020, 2021, and 2022 quarters and did not affect its ability to fully obligate the distributed funds, with its corrected lost revenues reflecting $2,589,831 in lost revenues. CHC has a strong record of grant compliance demonstrated by its consistent compliance with its financial statement audits and its clean record of compliance with its HRSA surveyors. We take our grant compliance seriously and have adequate internal controls in place to maintain current and future federal grants. We will strengthen our departmental allocation methodology of the Iowa Medicaid wrap-around payments with the following: • Re-educating its current accounting staff on the correct allocation methodology for Iowa Medicaid wrap-around payments. • Ensuring its dental payor wraparound payments are allocated correctly to its internal dental departments. This process will be monitored and completed through its monthly account reconciliation process and quarterly departmental reporting processes. • Ensuring its medical payor wraparound payments are allocated correctly to its internal medical departments. This will be done by utilizing a consistent allocation methodology based upon patient visits. This process will be monitored and completed through its monthly account reconciliation process and quarterly departmental reporting processes. The timing of the implemented corrective actions began in 2023 and has been re-enforced with its accounting staff in the first 2 quarters of 2023. As CHC has been able to fill its open accounting positions and train appropriately, I do not anticipate further Iowa Medicaid wrap allocation deficiencies. As such I consider all remediation steps to be implemented and complete.

View Audit 836

Finding 361 (2023-003)

Significant Deficiency 2023

Sebeka Public Schools

MN

Allowable Costs / Cost Principles Cash Management Eligibility

Contact Person – Superintendent; Corrective Action Plan – The District has established a procedure for review of journal entries; Completion Date – Completed

View Audit 736

Finding 342 (2022-002)

Significant Deficiency 2023

Arrive Ministries

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. ...

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. Recommendation: The Organization implemented a process to maintain documentation of the Executive Director’s approval for all pay periods. Corrective Action: We have already implemented a process for retaining the emails approving payroll period time cards by the Director and Executive Director. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 11/1/2022

View Audit 718

Finding 341 (2022-001)

Significant Deficiency 2023

Arrive Ministries

MN

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LT...

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LTD. 220 Park Avenue South St. Cloud, Minnesota Audit period: APRIL 1, 2022 TO MARCH 31, 2023 The findings from the September 5, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD Assistance Listing Number: 19.510 Federal Program Name: U.S. Refugee Admissions Program Name of Federal Agency: Department of State Finding 2022-001 - Time and Effort Reporting Recommendation: The Organization implement a process to track employee’s time and effort worked on federal programs. Corrective Action: We have implemented a process for employees to certify their time charged to federal programs on a monthly basis. We then adjust the financials as needed. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 12/1/2022

View Audit 718

Finding 305 (2023-002)

Significant Deficiency 2023

Vermont Student Assistance Corporation

VT

Cash Management Allowable Costs / Cost Principles § 200.303

Recommendation: We recommend management perform a documented review of the federal drawdowns to ensure the benefits reimbursement rate is timely updated in accordance with the requirements of new grant awards. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...

Recommendation: We recommend management perform a documented review of the federal drawdowns to ensure the benefits reimbursement rate is timely updated in accordance with the requirements of new grant awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has directed the Finance Department to review all draw down worksheets to insure that draw down parameters agree with all grant proposal, budget and award documents. Name(s) of the contact person(s) responsible for corrective action: Bruce Hicken, Controller Planned completion date for corrective action plan: No later than October 31, 2024.

View Audit 579

Finding 70 (2023-002)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to...

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. To ensure compliance with this requirement, Freestore Foodbank Inc. and Affiliates require all local distributors receiving commodities to sign a local distributor agreement. Condition: CSH noted two instances (in a sample of 40 local distributor agreements) where food was distributed to religious organizations that do not abide by 45 CFR 260.34. Planned Corrective Action: In one instance, management issued food to an agency which had an expired local distributor agreement. Going forward, controls will be put in place by 9/30/23 to better track agency agreements to ensure all agencies receiving food have up-to-date agreements. The second instance involved the request for TANF food to be distributed to an organization who was not participating in the program. While the organization was correctly set up in our database, food was requested to be distributed. Management will improve training for staff and run periodic reports to ensure food is going to the proper organizations. Management will also set up periodic compliance meetings with program managers to develop best practices for each of the grants by 10/31/23.

View Audit 63

Finding 67 (2023-001)

Significant Deficiency 2023

Clackamas County Childrens Commission

OR

Allowable Costs / Cost Principles

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation ra...

Corrective Action: The error identified related to a recurring accounts payable invoice template that is available to, and pending in, future accounting periods and posted monthly. The recurring invoice template was not updated at the time the distribution code was changed for current allocation rates. The template has since been updated. We will continue to review the transactions prior to posting in the accounting system to correct any errors. Anticipated Completion Date: August 2023

View Audit 62

Finding 1166291 (2022-005)

Material Weakness 2022

Rehoboth McKinley Christian Health Care Services, Inc.

NM

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.302

Management will enforce existing internal control procedures and train staff to maintain appropriate documentation.

View Audit 377383

Finding 1166168 (2022-003)

Material Weakness 2022

City of Watertown

MA

Allowable Costs / Cost Principles Significant Deficiency

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented...

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented approval for all grant-funded purchases, and maintaining adequate supporting documentation. Time and effort reporting processes will be reinforced. Grant monitoring procedures will include periodic allowability reviews. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

View Audit 377065

Finding 1166166 (2022-002)

Material Weakness 2022

City of Watertown

MA

Allowable Costs / Cost Principles § 200.430

Re: Corrective Action Plan - Audit Finding 2022-02 - Improve Controls and Documentation over Payroll Planned Corrective Action: The District will enhance payroll documentation controls by standardizing processes for verifying pay rates, retaining payroll support documents, and documenting/approving ...

Re: Corrective Action Plan - Audit Finding 2022-02 - Improve Controls and Documentation over Payroll Planned Corrective Action: The District will enhance payroll documentation controls by standardizing processes for verifying pay rates, retaining payroll support documents, and documenting/approving transfers and allocations. Cross-department procedures between Payroll, HR, and Business Office will be formalized. Staff involved in payroll and federal grants will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

View Audit 377065

Finding 1166164 (2022-001)

Material Weakness 2022

City of Watertown

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procu...

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procurement, conflicts of interest, cash management, travel, time and effort, inventory management, and record retention. All procedures will be consolidated into a Federal Grants Procedures Manual, approved by leadership, and reviewed annually. Relevant staff will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature

View Audit 377065

Finding 1165300 (2022-003)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.319

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including che...

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including checklists for method of procurement, contractor selection, cost/price analysis, and justification, and will be used for all purchasing actions. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● April 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1165299 (2022-002)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.328 § 200.400 § 200.430

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these record...

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1164212 (2022-001)

Material Weakness 2022

County of Belknap, New Hampshire

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director

View Audit 373506

Corrective Action Plans

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