Corrective Action Plans

Finding 390368 (2023-007)

Material Weakness 2023

NY

Reporting Internal Control / Segregation of Duties Cash Management

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary p...

The City Controller, City Engineer and Director of Community and Economic Development have held recent meetings to discuss the development of a SharePoint site for all grant documentation. Thus far, there has not been a centralized location for award documents that can be accessed by all necessary parties. A draft SEFA worksheet will be created and updated on an ongoing basis throughout the fiscal year. This will improve the accuracy of internal federal award data. Louise Biron will be responsible for this finding and the anticipated completion date is June 30, 2024.

View Audit 301192

Finding 390273 (2023-006)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radi...

REFERENCE: 2023-006 – Reporting – Common Origination and Disbursement (COD) System Student Financial Assistance Cluster (Assistance Listing Nos. 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan origination and disbursement records to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management for presentation to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will review their processes to develop and implement internal controls that ensure compliance with federal regulations. Evidence of the internal control being performed will be retained. Person Responsible: Judy Kronenberger, President Good Samaritan College of Nursing and Health Science and Financial Aid Services (FAS) David Velasquez, Nuclear Medicine Technologist Coordinator (CHI Health School of Radiologic Technology) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390270 (2023-005)

Material Weakness 2023

Commonspirit Health

IL

Student Financial Aid Matching / Level of Effort / Earmarking Cash Management § 200.303

REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samar...

REFERENCE: 2023-005 – Cash Management Student Financial Assistance Cluster (Assistance listing No. 84.007, 84.063, 84.268) Federal Grantor: U.S. Department of Education Facility: Good Samaritan College of Nursing and Health Science and CHI Health School of Radiologic Technology Finding: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Corrective Action Plan: This finding has been corrected for Good Samaritan. In May of 2023, for April 2023 data, Good Samaritan implemented a formal monthly reconciliation process, including comparison of all systems for the period, a final review of G5 funds prior to draw down, a cover sheet noting any explaining any differences, proper sign off for preparation and review and the date by Good Samaritan management and FAS management. This review is presented monthly to the Compliance Oversight Committee. A year end reconciliation is also performed following the same process. CHI Health School of Radiologic Technology will implement a review control for accounting staff to review the draw down amount provided by the School prior to completing the drawn down. Documentation of the review will be retained. Person Responsible: Judy Kronenberger, President, Good Samaritan College of Nursing and Health Science and Andrea Heffelfinger, Market Director of Accounting (CHI Health) Completion/Expected Completion: April 2023 (Good Samaritan)/June 2024 (CHI Health School of Radiologic Technology)

View Audit 301158

Finding 390260 (2023-103)

Material Weakness 2023

Maricopa County Community College District

AZ

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C2...

Assistance Listing number and name: 84.031 Higher Education – Institutional Aid Award numbers and years: P031S160090, October 1, 2016 through September 30, 2023 P031S190167, October 1, 2019 through September 30, 2024 P031S200096 and P031S200081, October 1, 2020 through September 30, 2025 P031C210057 and P031C210077, October 1, 2021 through September 30, 2026 P031S220015 and P031S220179, October 1, 2022 through September 30, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Reporting and special tests and provisions Questioned costs: Unknown Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Diana Aguirre-Rosales, Fiscal Director, Maricopa Community Colleges Foundation Anticipated completion date: December 31, 2024 The District is aware of the importance of ensuring that reports submitted are reviewed for accuracy prior to submission and implemented new processes for report review and submission in November 2023. On February 7, 2024, after multiple requests, the U.S. Department of Education (ED) provided the District with access to ED’s reporting system, which will allow the District to timely submit reports. The District will coordinate with the Maricopa Community Colleges Foundation to ensure that the endowment contracts include all necessary federal regulation information and that the investment and disbursement of funds are in accordance with federal regulations.

View Audit 301142 Questioned Costs: $1

Finding 390252 (2023-002)

Significant Deficiency 2023

Kvc Health Systems, Inc.

KS

Cash Management Reporting Internal Control / Segregation of Duties

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and ...

KVC Hospitals, Inc. - Effective Internal Controls related to the Financial Statements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The Organization is going to continue and improve its understanding of the guidance related to this type of reporting and work with their external advisors to ensure future portal submissions are compliant with said guidance. Going forward, the Organization will continue to improve its internal controls related to lost revenue calculations and reporting and work with their external advisors to ensure future portal submissions, if any, are compliant with said guidance. The under-reporting of lost revenues had no impact on the Organization’s ability to cover the total Provider Relief Fund payments received. This review will be performed by June 30, 2024. Responsible Official: Sherri Lohe Chief Financial Officer

View Audit 301134

Finding 390226 (2023-002)

Significant Deficiency 2023

Do Good Multnomah

OR

Allowable Costs / Cost Principles Cash Management Reporting

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices ...

We have implemented additional levels of approval and oversight for point-of-sale and invoice spending to ensure that receipts are captured and retained correctly, and that at invoices are reviewed and approved before payment. We have also provided additional training for spenders on best practices of recording and maintaining records. We have since also consolidated our supply chain so that spenders are able to procure most supplies through one vendor, which will have reporting and tracking capabilities. We will also be making significant changes to how mileage reimbursement is documented and approved.

View Audit 301123

Finding 390194 (2023-001)

Material Weakness 2023

College Dreams, INC

OR

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (sc...

Finding # 2023-001 Material weakness over allowable costs U.S. Department of Education 84.044A TRIO Programs Cluster: TRIO – Talent Search Finding: Only allowable costs may be charged to the contract for reimbursement. One out of six invoices charged to the contract was an unallowable expense (scholarships). Recommendation: Expenses charged to contract should be reviewed thoroughly and be in compliance with contract agreement. Management should have understanding of what costs are considered allowable and unallowable. Corrective Action: We will have the Executive Director, Business Manager and College+ Program Manager thoroughly review the monthly Talent Search billing before completing a drawdown to ensure that all expenses billed are allowable costs. Anticipated Completion Date: June 30, 2024

View Audit 301101

Finding 390163 (2023-005)

Material Weakness 2023

Yukon Flats School District

AK

Cash Management Material Weakness Reporting

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calenda...

Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: YFSD hired an experienced and independent contract grants specialist. She is using Outlook to set up reporting reminders to ensure timely submission of reports. In addition, the Business office started using a calendar developed by ALASBO which addresses all reporting requirements for the school districts in Alaska. Proposed Completion Date: March 31, 2024

View Audit 301080

Finding 390159 (2023-003)

Significant Deficiency 2023

City of Daly City

CA

Questioned Costs Cash Management § 200.305

Finding Reference Number: SA2023-003 Cash Management - Draw Down of Community Development Block Grant Funds in Advance of Disbursement Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Bloc...

Finding Reference Number: SA2023-003 Cash Management - Draw Down of Community Development Block Grant Funds in Advance of Disbursement Assistance Listing Number: 14.218 Assistance Listing Title: Community Development Block Grant – Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-22-MC-06-0010 COVID-19 - B-20-MW-06-0010 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Traci Cho, Accountant • Corrective Action Plan: The City will review the retentions payable when preparing the IDIS drawdown to ensure that retentions are not included in the drawdown amount. • Anticipated Completion Date: 06/30/24

View Audit 301060 Questioned Costs: $1

Finding 390136 (2023-001)

Significant Deficiency 2023

Northeast Colorado Board of Cooperative Educational Services

CO

Cash Management Subrecipient Monitoring Material Weakness § 200.305

Management Response: The BOCES will assure internal control procedures are in place to verify that all grant funding requests meet Cash Management requirements. Reimbursements will be requested subsequent to the expenditure of grant funds. The BOCES will establish internal controls whereby the gran...

Management Response: The BOCES will assure internal control procedures are in place to verify that all grant funding requests meet Cash Management requirements. Reimbursements will be requested subsequent to the expenditure of grant funds. The BOCES will establish internal controls whereby the grant manager determines the amount to be requested and this will be subsequently verified by finance staff to ensure that total requests do not exceed incurred or obligated expenditures. A review of the internal control procedures with all grant management and finance staff will assure that this is not a reoccurring issue.

View Audit 301027

Finding 389987 (2023-001)

None 2023

Queens University of Charlotte

NC

Cash Management

Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS ear...

Individual Responsible for Corrective Action: Don Barton, Controller Corrective Action: Cash management of Title IV funds at the University is generally performed only on a reimbursement basis. In this situation there was a one-time error in calculating available FWS funds and year-to-date FWS earnings such that approximately $11,000 in excess cash was received near the end of the 21-22 year and then carried forward. The error was discovered early in 22-23 but by that point earnings had outpaced cash on hand and so no effort was made to return funds. A new procedure with a multi-year workbook has been established for monitoring FWS earnings across award periods to prevent a repeat occurrence. Anticipated Completion Date: August 15, 2024

View Audit 300901

Finding 389978 (2023-007)

Significant Deficiency 2023

Youth & Shelter Services, INC

IA

Cash Management

As mentioned previously, there was a staffing change with a grant billed which helped make YSS aware of an internal control breakdown in the billing process. Along with the issue where revenue was posted but invoices were not sent, it was also found that many workpapers that should have been in pla...

As mentioned previously, there was a staffing change with a grant billed which helped make YSS aware of an internal control breakdown in the billing process. Along with the issue where revenue was posted but invoices were not sent, it was also found that many workpapers that should have been in place to support the invoices were disorganized, lacked an audit trail, or in some cases did exist aside from a handful of brief notes, especially in cases where grants were drawn in 1/12th increments. While many worksheets were created or greatly enhanced already, the grant billers are currently engaging in a new process to begin cost tracking for the grants which have allowed 1/12th without consistently asking for such supporting workpapers.

View Audit 300877

Finding 389917 (2023-003)

Material Weakness 2023

El Paso Las Puertas Abiertas, Inc.

TX

HUD Housing Programs Special Tests & Provisions Cash Management

Special Tests and Provisions: In accordance with the Project's regulatory agreement with HUD, management shall establish a residual receipts account and make deposits into the account in accordance with HUD requirements (within 90 days after the close of the fiscal year). Disbursements from such fun...

Special Tests and Provisions: In accordance with the Project's regulatory agreement with HUD, management shall establish a residual receipts account and make deposits into the account in accordance with HUD requirements (within 90 days after the close of the fiscal year). Disbursements from such fund may be made only after written consent is received from HUD, Management's View: Management acknowledges finding and simultaneously underscores this was an internal facing situation. Proposed Corrective Action: Management will ensure that all proper approvals from HUD are obtained before making a withdrawals from residual receipts account. Anticipated Correction Date: Correction has been implemented.

View Audit 300827

Finding 389914 (2023-001)

None 2023

Stansbury Homes, INC

MD

Cash Management HUD Housing Programs Reporting

We agree with this finding and have taken steps to prevent this from occurring in the future. Our policy has been to make surplus cash deposits after the final audit has been issued. A residual receipts account has been established and the required fiscal year 2022 surplus cash deposit of $17,660 ha...

We agree with this finding and have taken steps to prevent this from occurring in the future. Our policy has been to make surplus cash deposits after the final audit has been issued. A residual receipts account has been established and the required fiscal year 2022 surplus cash deposit of $17,660 has been made to the account on October 21, 2022.

View Audit 300807

Finding 389897 (2023-001)

Material Weakness 2023

Wide Ruins Community School

AZ

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management

Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician...

Finding Number: 2023‐001 Program Names/Assistance Listing Titles: Indian School Equalization, Administrative Cost Grants for Indian Schools, Indian Education Facilities, Operations and Maintenance Assistance Listing Numbers: 15.042, 15.046, 15.047 Contact Person: Stephanie Woody, Business Technician; Aurelia Tapaha, Business Manager/Human Resource Manager; Jeannie Lewis, Principal Anticipated Completion Date: July 2024 Planned Corrective Action: The School will review the procurement flowcharts and required documents for Business Technician. The School will obtain training for chart of accounts training for business staff along with procurement training. Business staff and administrators will keep abreast of law changes, GASB updates, and budget changes with grants received. The School will review school credit and implement a timeframe where the no use of the credit card is enforced. The School will collect all required documents to process payments. The entire balance will be paid in full amount for each month. Training on use of credit cards will be given during orientation.

View Audit 300789

Finding 389890 (2023-001)

Significant Deficiency 2023

Pennsylvania College of Art & Design

PA

Questioned Costs Cash Management

Finding_ 2023-001 Recommendation: The college should establish procedures to ensure proper review and compliance with disbursements of federal funds, including controls over compliance, to ensure that federal funds are disbursed to student accounts in a timely manner in accordance with federal regul...

Finding_ 2023-001 Recommendation: The college should establish procedures to ensure proper review and compliance with disbursements of federal funds, including controls over compliance, to ensure that federal funds are disbursed to student accounts in a timely manner in accordance with federal regulations and conditions. Corrective Action: A control has been added to reconcile the posting of student federal monies with federal funds received by the college. The VP of Finance and Administration with coordinate with the Financial Aid officer to ensure funds are properly posted in a timely and compliant manner. Person Responsible for Corrective Action: Michael Molla, President Anticipated Completion Date for Corrective Action: The Corrective Action will be immediately implemented in response to the auditor's recommendation.

View Audit 300776 Questioned Costs: $1

Finding 389873 (2023-002)

Significant Deficiency 2023

Northern Essex Community College

MA

Questioned Costs Cash Management

Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F, 84.425L Award year: 2023 Corrective Action Plan: We agree with this audit finding. As stated in our response to the prior year audit’s find...

Finding number: 2023-002 Federal agency: U.S. Department of Education Programs: Higher Education Emergency Relief Fund Assistance Listing #: 84.425F, 84.425L Award year: 2023 Corrective Action Plan: We agree with this audit finding. As stated in our response to the prior year audit’s finding, we did not realize that under the HEERF III Issued Guidelines/(FAQs) that as a grantee we were under an obligation to minimize the time between drawing down funds from G5 and paying obligations incurred by the college/grantee. We had thought that the related guidelines were similar to CARES/HEERF I and we wanted to ensure that we had drawn down the funds timely once they were awarded to the college. We have since coordinated with the Office of Postsecondary Education, United States Department of Education to reimburse them for interest income earned on unspent funds and returned the remaining/unused funds for the HEERF III Institutional Aid portion and the Minority Serving Institutional Funds portion. The College spent $41,007 of the remaining HEERF III Institutional Aid funds during the 90-day HEERF liquidation period after discussion with the United States Department of Education and returned the remaining amount of $70,031 in February 2024. The College returned the HEERF III Minority Serving Institutional Funds remaining amount of $144,014 in February 2024. The interest the College earned and returned to the United States Department of Education on the unspent funds amounted to $125,324, which was paid in two installments in July 2023 and February 2024. Timeline for Implementation of Corrective Action Plan: The corrective action plan has been implemented as of January 8, 2024. Contact Person Anthony DeGregorio, Comptroller & Director of Fiscal Services

View Audit 300758 Questioned Costs: $1

Finding 389864 (2023-004)

Significant Deficiency 2023

Home Healthcare, Hospice & Community Service, Inc. & Affiliate

NH

Cash Management Reporting

The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Grant/Staff Accountant and/or Senior Accountant to ensure that monthly Meals on Wheels sp...

The Accounting Manager will educate the Senior Management Team so that all departments are aware of this finding and the steps to prevent its recurrence. The Accounting Manager will work in conjunction with the Grant/Staff Accountant and/or Senior Accountant to ensure that monthly Meals on Wheels spreadsheet totals reconcile with the meals within the Serv Tracker reporting. Procedures will be revised as necessary and documented. Staff will be trained on new procedure. Responsible Party: Judy Arellano Accounting Manager 603-352-2253 Anticipated Completion Date: 4/15/24

View Audit 300747

Finding 389821 (2023-001)

None 2023

Stevenson University, Inc.

MD

Cash Management Student Financial Aid

Name of Responsible Individual: Mary Beth Schiller-Schwenke, Controller Corrective Action: The FWS Program instances were the result of a minor type error on the federaldraw reconciliation worksheet. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping pr...

Name of Responsible Individual: Mary Beth Schiller-Schwenke, Controller Corrective Action: The FWS Program instances were the result of a minor type error on the federaldraw reconciliation worksheet. To prevent a similar error in the future, the Business Office has modified its draw recordkeeping process to require the employees that record or approve the draw journal entry also review the draw worksheet for accuracy and correct if needed. The FSEOG Program instances resulted from reversals of student awards in fiscal year 2024 for the fiscal year 2023. The Business Office routinely monitors the general ledger for award transactions, however, reversals of student aid awarded in a prior fiscal year can be offset by current year activity and missed. The Financial Aid Office will be responsible to notify the Business Office when they initiate prior award transactions. In addition to the weekly monitoring of the related general ledger accounts, the Business Office will also generate financial aid award reporting and monitor for changes. Anticipated Completion Date: February 28, 2024

View Audit 300714

Finding 389810 (2023-002)

Significant Deficiency 2023

The Cleveland Play House

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.302 § 200.403 § 200.430

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are stan...

Finding Number: 2023-002 Planned Corrective Action: Cleveland Play House had extensive turnover during the 2022 and 2023 fiscal years which resulted in several vacancies, including the Director of Finance position, for a significant portion of the year. As a result, many of the reports that are standard practice in our organization were not being completed. In addition, the filing of certain documentation to support expenditures was not being done consistently. The Director of Finance position was not filled until November 2022. As a result, documentation of allowable expenditures is being addressed for the fiscal 2023 audit. In addition to turnover, the organization transitioned to a new general ledger system with a new chart of accounts in fiscal year 2022. As a result of this transition and the vacancies mentioned above, certain data pertaining to the federal programs was not being captured. Management has informed all staff of the requirements to track federal programs within the general ledger accounts. Anticipated Completion Date: September 30, 2024 Responsible Contact Person: Erica Tkachyk, Director of Finance

View Audit 300711 Questioned Costs: $1

Finding 389809 (2023-001)

Significant Deficiency 2023

City of Naples Airport Authority

FL

Cash Management Matching / Level of Effort / Earmarking Significant Deficiency § 200.306

Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ab...

Views of responsible officials and planned corrective action: The Authority acknowledges that this error occurred. When we identified this issue, we contacted the grantor agency for guidance. They explained how to submit a refund and acknowledged that since the grant was still open, we had the ability to correct an incorrect draw. This refund has been processed and the Authority has put additional internal controls in place to ensure the proper match is calculated for each grant draw in the future. Additionally, upon final grant closeout, all the numbers are verified and reconciled back to the grant agreement, including the match.

View Audit 300702

Finding 389785 (2023-001)

Significant Deficiency 2023

Jackson Public School District

MS

Subrecipient Monitoring Cash Management Reporting

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Jackson Public School District has prepared and hereby submits the following corrective a...

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Jackson Public School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Marc Rowe Title: Executive Director B. Description of corrective action planned: The district will implement and strengthen its internal control systems over reporting and submitting its monthly claims for reimbursement to ensure claims are submitted within established reporting deadlines. C. Anticipated completion date of corrective action: 6/30/2024

View Audit 300692

Finding 389765 (2023-002)

Significant Deficiency 2023

Homeward Bound of Western North Carolina, Inc.

NC

Cash Management Significant Deficiency

Name of Contact Person: Suzy Johnson, Director of Finance & Operations Corrective Action: All grant billing projection sheets will be completed on a monthly basis and given to the appropriate program director for review and approval before any grant draws are initiated. Completion Date: On or by ...

Name of Contact Person: Suzy Johnson, Director of Finance & Operations Corrective Action: All grant billing projection sheets will be completed on a monthly basis and given to the appropriate program director for review and approval before any grant draws are initiated. Completion Date: On or by June 30, 2024

View Audit 300656

Finding 389752 (2023-004)

Material Weakness 2023

County of Ventura

CA

Special Tests & Provisions Cash Management Material Weakness

Program: COVID-19 Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No. and Year: Various Compliance Requirements: Special Tests and Provisions Type of Finding: Material Weakness in Internal Control ov...

Program: COVID-19 Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No. and Year: Various Compliance Requirements: Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees with the recommendation to strengthen the established policies and procedures to ensure that the sliding fee discount program schedules are applied to patient charges consistent with its sliding fee discount schedule, and to ensure that County personnel strictly adheres to policies and procedures. View of Responsible Officials and Corrective Action: HCA management recognizes that the sliding fee discount schedule/discount grid established in 2020 was complex and may have contributed to errors in adjustments. A new fee schedule was developed in 2023 to establish flat fees that are more inclusive of services. The grid established in 2020 was in effect until the new grid was approved by the Board of Supervisors on March 15, 2023. Most of the encounters selected for review were encounters dated prior to the new grid’s effective date. HCA management has strengthened its sliding fee policy and procedure, approved by the Board of Supervisor on March 15, 2023. HCA management will implement the following internal control process to ensure that adjustments are consistent with the sliding fee discount program fee schedule: 1. All Medical Billing Specialists responsible for enrolling patients into the sliding fee program will be retrained on eligibility and adjustments. 2. To ensure that patients have received the correct adjustment, we will run a report of all patients under the sliding fee program with at least one encounter, year to date. All applications, proof of income, program eligibility, and adjustments will be reviewed for each patient. Corrections will be made, if applicable. 3. For the remaining of FY 22/23, a monthly report of all encounters under the sliding fee discount program will be pulled and reviewed monthly for accuracy. Corrections will be made and staff will be trained, as needed. 4. Starting in FY 23/24, a random sampling of sliding fee discount program encounters per Federally Qualified Health Center will be audited monthly to ensure accuracy and timely adjustment of encounters. Results will be trended to address any additional process improvements. COUNTY OF VENTURA, CALIFORNIA CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2023 6 Name of Responsible Persons: Lizeth Barretto, Ambulatory Care COO – Ms. Barretto will ensure that the activities listed in the Corrective Action Plan are executed until an Ambulatory Care CFO and/or Ambulatory Care Patient Revenue Manager is hired. Ambulatory Care CFO (Vacant) – Establishes sliding fee discount program policy, procedures, and fee schedules. Ambulatory Care Patient Revenue Manger (Vacant) – Responsible for the oversight of the Medical Billing Specialists responsible for sliding fee discount eligibility and adjustments. Implementation Date: April 15, 2024, Training of Medical Billing Specialists and monthly encounter review and corrections. April 22, 2024, Year to date report and internal audit August 5, 2024, Monthly sampling of encounters

View Audit 300633

Finding 389707 (2023-004)

Material Weakness 2023

Fort Scott Community College

KS

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Views of responsible officials and planned corrective action: Areas of focus will be to put in place written policies and procedures for the Financial Aid office, including the area of disbursements that includes additional controls and documentation of such. Our objectives will be that all current ...

Views of responsible officials and planned corrective action: Areas of focus will be to put in place written policies and procedures for the Financial Aid office, including the area of disbursements that includes additional controls and documentation of such. Our objectives will be that all current and incoming Financial Aid staff will be required to maintain documentation of any drawdowns of funds related to student financial aid. We have put in place a shared an electronic folder with restricted access to provide confidentiality and provide documentation of the shared communication between offices. Documentation of drawdowns and/or returns will be maintained within this folder. Staff will be trained on using the daily generated reports from Poise to watch for students who have withdrawal on their records so that this can be updated and proper calculations done. Measurable targets will be achieved by documenting the records within a shared electronic drive between the Financial Aid office and the Business Office, who handles the return of funds. This will become of a part of the weekly duties of staff.

View Audit 300625

Corrective Action Plans

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