Corrective Action Plans

Finding 4907 (2023-001)

Significant Deficiency 2023

MA

Questioned Costs Cash Management School Nutrition Programs

Condition: The District’s school lunch office maintained production records and manual count sheets instead of using the point-of-sale system for tracking student meal counts. Corrective Action Planned: The District has implemented a point-of-sale system for sales of meals and will use system rep...

Condition: The District’s school lunch office maintained production records and manual count sheets instead of using the point-of-sale system for tracking student meal counts. Corrective Action Planned: The District has implemented a point-of-sale system for sales of meals and will use system reports as support for the monthly claims for reimbursement. Anticipated Completion Date: September 2023 Contact: Ann-Marie Geyster, School Business Manager

View Audit 7093

Finding 4883 (2023-002)

Significant Deficiency 2023

Muskegon Area Intermediate School District

MI

Allowable Costs / Cost Principles Reporting Cash Management § 200.430

Finding 2023-002: Special Education Cluster Semi-Annual Certification Procedures Recommendation: The School District should provide training to educate all employees working in federal programs of the requirements for documenting personnel expenses under Uniform Grant Guidance, and the School Di...

Finding 2023-002: Special Education Cluster Semi-Annual Certification Procedures Recommendation: The School District should provide training to educate all employees working in federal programs of the requirements for documenting personnel expenses under Uniform Grant Guidance, and the School District should require proper time-and-effort documentation to be timely reviewed and approved by the appropriate program supervisor. Action Taken: Trainings will be provided to all directors of federally funded programs regarding the semi-annual certification process. Certifications will be performed by all federally funded staff two times each year. The first certification is due to the Director of Fiscal Services no later than January 15 of each year. The second certification is due to the Director of Fiscal Services office no later than July 15 of each year. Certification records will be verified and maintained by the Director of Financial Services. Responsible Person and Anticipated Completion Date: Director of Financial Services, November 2023. If the Michigan Department of Education has questions regarding this plan, please call Jesse Rickard at (231) 767-7209.

View Audit 7049

Finding 4873 (2023-001)

Material Weakness 2023

Child Lane

CA

Cash Management School Nutrition Programs

Child Lane management staff re-assessed program staff access to determine the changes that needed to be made in order to protect program integrity. To ensure valid DCH claims are submitted the following steps were taken:1. Employment was terminated for the staff person involved in the invalid DCH nu...

Child Lane management staff re-assessed program staff access to determine the changes that needed to be made in order to protect program integrity. To ensure valid DCH claims are submitted the following steps were taken:1. Employment was terminated for the staff person involved in the invalid DCH nutrition claims.2. Child Lane changed Field Representatives from working from home and provided work stations at the Administrative Office instead effective July 1, 2023. 3. A police report was filed with the Signal Hill Police Department.4. A claim was submitted with Great American under Child Lane’s employee fraud insurance policy.5. User names and passwords were reset for all staff and staff were re-trained.6. Child Lane added a Quality Assurance Specialist whose responsibility is to assist in enforcing all CACFP program policies, procedures, and guidelines. 7. Child Lane management re-assigned providers to a different Field Representative.8. Child Lane staff conducted household contact verification to approximately 150 provider enrollments out of the approximate 450 providers that were claiming at the time.9. Child Lane limited access for CACFP Field Representatives so that they are not able to make changes to provider profiles. Only the nutrition program manager is able to make changes.10. All prospective DCH providers speak to the program manager and only the program manager and one other staff person are responsible for signing new providers.11. The direct deposit procedure was updated so that DCH providers complete the electronic forms themselves directly to their individual Paycom account, complete an electronic signature and complete a two-step verification process through Paycom when changes are made. Nutrition program staff is not able to make changes to direct deposit for DCH providers.12. Downward adjustment claims were submitted through Child Lane’s CNIPS account for the invalid claims that were identified. The downward adjustments were reduced from current claim reimbursements. An email was received on November 17, 2023 by the California Department of Social Services, (CDSS) Fiscal Policy and Analysis Bureau verifying that all the associated downward adjustment claims were processed and deducted from current claim reimbursements. 13. Entries were made on Child Lane’s GL to recognize the reduction in income due to the downward adjustment claims submitted to agree with CDSS claim reimbursements for 2022-2023 Fiscal Year. The amount for previous Fiscal Years was posted to Contracts Settlements under the Management and General cost center. An entry was made as of June 30, 2023 to reduce the Family Day Care Contracts CACFP expense for the invalid claims for Fiscal Year 2022-2023 and offset to the Family Day Care Contracts expense under the Management and General cost center. Name of Contact Person Responsible for Planned Corrective Actions: Maria Almeida, Contracts & Compliance Manager Anticipated Completion Date: November 30, 2023

View Audit 7032

Finding 4494 (2023-002)

Significant Deficiency 2023

Lewis County C-1 School District

MO

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.302

This following is submitted as our management response to the audit finding regarding Allowable Costs Reporting in the District’s FY23 Audit. At the close of Fiscal Year 2023, the District submitted a payment request for federal ESSER reimbursement, encompassing eligible employee expenses spanning ...

This following is submitted as our management response to the audit finding regarding Allowable Costs Reporting in the District’s FY23 Audit. At the close of Fiscal Year 2023, the District submitted a payment request for federal ESSER reimbursement, encompassing eligible employee expenses spanning multiple years in accordance with ESSER guidelines. However, an administrative oversight became apparent, as the expense codes and ASBRs for the relevant years had not been amended to align with the represented expenditures. To address this, the District is undertaking a meticulous correction process through adjusting journal entries. This corrective action will ensure that the expense codes accurately reflect the corresponding project codes and Fiscal Year expenditures. Simultaneously, the ASBRs for the affected years will be resubmitted, aligning with the requisite financial standards. Looking ahead, the District is instituting a proactive measure to prevent recurrence. The superintendent, or a designated district representative, will verify that the District's accounting software records, as compiled by the District Bookkeeper, impeccably mirror the accurate totals for expense codes, incorporating the requisite accounting codes, including project codes. This validation will be a prerequisite before any future reimbursement request for federal funds is submitted, ensuring a heightened level of precision and compliance in financial reporting. These measures underscore the District's commitment to fiscal accountability, rectifying oversights, and fortifying internal controls to uphold the integrity of financial processes. The district will begin immediately implementing the revised proactive measures and is in the process of rectifying the noted issues with corrective journal entries. This process will be updated prior to January 15, 2024. Should you need anything further from the district, please do not hesitate to contact me.

View Audit 6979

Finding 4479 (2023-001)

Significant Deficiency 2023

Sandusky Community Schools

MI

School Nutrition Programs Questioned Costs Subrecipient Monitoring

Recommendation: The District should verify that all required components of meal applications are completed fully and accurately and that income eligibility is recalculated accurately prior to approval. Action to be taken: The District concurs with the facts of this finding and will verify that all i...

Recommendation: The District should verify that all required components of meal applications are completed fully and accurately and that income eligibility is recalculated accurately prior to approval. Action to be taken: The District concurs with the facts of this finding and will verify that all income eligibility is recalculated accurately prior to approval.

View Audit 6966 Questioned Costs: $1

Finding 4478 (2023-001)

Significant Deficiency 2023

The Russell Child Development Center, Inc.

KS

Allowable Costs / Cost Principles Cash Management Eligibility

SIGNIFICANT DEFICIENCY 2023-001 Eligibility and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Condition Four providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that comple...

SIGNIFICANT DEFICIENCY 2023-001 Eligibility and Activities Allowed or Unallowed and Allowable Costs/Cost Principles Condition Four providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Recommendation The CACFP at The Russell Child Development Center, Inc. is aware of the oversight and will continue to strive to improve its review process. Action Taken: As of November 1, 2023, CACFP staff verify that the tally marks from the paper claims match the total provided. Those tally marks are then entered into My Food Program, and the total is again verified to match the paper claim. Manual claim adjustments will be saved and filed with supporting documentation, if applicable.

View Audit 6959

Finding 4386 (2023-001)

Material Weakness 2023

Chesterfield County School District

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

Corrective Action: The District has implemented additional internal controls and monitoring around claiming and reconciling federal funds. Additional Controls are listed below: 1. A reconciliation of all federal funds will be done prior to the state claiming deadline of August 15th. 2. A spreadshee...

Corrective Action: The District has implemented additional internal controls and monitoring around claiming and reconciling federal funds. Additional Controls are listed below: 1. A reconciliation of all federal funds will be done prior to the state claiming deadline of August 15th. 2. A spreadsheet has been developed that will be maintained by the CFO for any and all grants that are processed through the state GAPS system. This document will allow the district to better monitor timeliness and accuracy of claims. It will detect and prevent any variance in federal budgeting within GAPS or variances between expenditures and related claims. 3. Each federal program will be required to submit a claim packet each quarter regardless of the existence of expenditures. If there are no expenditures related to a grant in a particular quarter. This documentation will serve as a notification that there should be no claim for the quarter and it will be noted on the spreadsheet mentioned in internal control #1. 4. Each federal program office will be required to submit, along with their normal claim packet, a year-to-date report in addition to the normal quarterly report. This addition will detect any claims that may have been missed earlier in the year. In addition to these controls, additional training has been provided to each affected federal program and every federal program is now required to have quarterly pre-claim meetings with the Chief Financial Officer to ensure adequate and accurate communication and to ensure expenditures and claims are progressing timely. Responsible Officials: Kevin Caskey, CPA - Chef Financial Officer - (843) 680-6013 Anticipated Completion: Immediately

View Audit 6820

Finding 4294 (2023-003)

Significant Deficiency 2023

Portage Path Behavorial Health

OH

Cash Management Reporting Matching / Level of Effort / Earmarking

Management has reviewed the finding and is in agreement with the reported deficiency as a result of staffing levels. Corrective action will include evaluation of existing accounting staffing levels, review of current accounting policies related to separation of duties, and the addition of a requirem...

Management has reviewed the finding and is in agreement with the reported deficiency as a result of staffing levels. Corrective action will include evaluation of existing accounting staffing levels, review of current accounting policies related to separation of duties, and the addition of a requirement for secondary approval related to journal entries, SEFA preparation, and draw requests for/from federal grant programs. To be completed within fiscal year 2024.

View Audit 6636

Finding 4289 (2023-001)

None 2023

13west 103rd Street CORP

NY

HUD Housing Programs Questioned Costs Cash Management

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently i...

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently in communication with HUD discussing options of a possible waiver for the required deposit or the possibility of making the deposit with promise of approval for immediate release

View Audit 6603

Finding 4288 (2023-001)

None 2023

1347 Morris Avenue Corporation

NY

HUD Housing Programs Questioned Costs Cash Management

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently i...

Actions Taken or Planned - Auditee agrees with this finding. Our policy has been to make surplus cash deposits after the final audit has been issued. Management has determined that making the required deposit will leave the entity with low funds to cover operation expenses. Management is currently in communication with HUD discussing options of a possible waiver for the required deposit or the possibility of making the deposit with promise of approval for immediate release

View Audit 6601

Finding 4270 (2023-004)

Significant Deficiency 2023

City Colleges of Chicago

IL

Questioned Costs Student Financial Aid Cash Management § 200.303

Finding 2023-004 – Cash Management – Excess Cash Condition During our cash management testing, we identified the following instances of excess cash: • Kennedy King College had excess cash for the Pell Grant Program ranging from $34,408 to $175,609 during the period of November 14, 2022 through Jan...

Finding 2023-004 – Cash Management – Excess Cash Condition During our cash management testing, we identified the following instances of excess cash: • Kennedy King College had excess cash for the Pell Grant Program ranging from $34,408 to $175,609 during the period of November 14, 2022 through January 31, 2023. In these situations, the excess cash exceeded one percent of total prior year drawdowns and amounts were not returned within a seven-day period. • Kennedy King College had excess cash for the Direct Loan Program ranging from $1,349 to $4,318 during the period of November 29, 2022 through December 13, 2022, from $1,508 to $3,948 during the period of January 6, 2023 through January 16, 2023 and from $3,207 to $5,137 during the period of June 15, 2023 through June 29, 2023. In these situations, the excess cash did not exceed one percent of total prior year drawdowns, however, amounts were not returned within a seven-day period. • Truman College had excess cash for the Pell Grant Program ranging from $164,625 to $262,034 during the period of November 14, 2022 through January 31, 2023. In these situations, the excess cash exceeded one percent of total prior year drawdowns and amounts were not returned within a seven-day period. • Truman College had excess cash for the Direct Loan Program ranging from $2,731 to$8,669 during the period of January 20, 2023 through February 16, 2023 and from $752 to $10,028 during the period of April 28, 2023 through June 29, 2023. In these situations, the excess cash did not exceed one percent of total prior year drawdowns; however, amounts were not returned within a seven-day period. Cause The College drew down funds available in the G5 system as opposed to drawing down expected student disbursement amounts. Corrective Action Taken or Planned District Office Financial Aid will develop and implement better controls and procedures for monitoring the timing of the draw downs and student disbursements as well as controls to monitor the return of excess cash, if any, within the 7-day period. During the middle of a semester, timely reconciliations will be prepared, reviewed and approved prior to the next draw down to ensure the acceptable amount is drawn down and disbursed timely to the students. Contact Person: Tiffany Morrison, Associate Vice Chancellor, Financial Aid Anticipated Completion Date: December 31, 2023

View Audit 6574 Questioned Costs: $1

Finding 4263 (2023-004)

Material Weakness 2023

W-A-Y Academy

MI

Questioned Costs Cash Management

Management believes that the previous Director of Finance drew down the funds in error. Going forward, a record of all funds drawn will be maintained and will include documentation to support the amount of the drawdown.

View Audit 6573 Questioned Costs: $1

Finding 4202 (2023-004)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

Internal Control / Segregation of Duties Cash Management Significant Deficiency § 200.303

Recommendation: Implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organizat...

Recommendation: Implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4145 (2023-001)

None 2023

University of Mount Olive, Inc.

NC

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

Name of Responsible Individual: Brian K. Blackburn, Director of Financial Aid Corrective Action: The University has implemented a weekly COD maintenance file update that will report any change activity to a student’s COD funds. This process is ensured to take place by ongoing calendar reminders as ...

Name of Responsible Individual: Brian K. Blackburn, Director of Financial Aid Corrective Action: The University has implemented a weekly COD maintenance file update that will report any change activity to a student’s COD funds. This process is ensured to take place by ongoing calendar reminders as well as progress checks between the Director and Assistant Director. Anticipated Completion Date: November 6, 2023

View Audit 6454

Finding 4143 (2023-004)

None 2023

University of Mount Olive, Inc.

NC

Special Tests & Provisions Questioned Costs Student Financial Aid

FINDING 2023-004 Name of Responsible Individual: Brian K. Blackburn, Director of Financial Aid Corrective Action: The link has been submitted to the Department of Education. Anticipated Completion Date: November 16, 2023

View Audit 6454

Finding 4133 (2023-004)

Material Weakness 2023

School District of Norwalk-Ontario-Wilton

WI

Questioned Costs Cash Management Reporting

Child Nutrition Reporting - Contact: Jeremy Mack, Business Agent. Completion date: June 30, 2024. The District administrator has reviewed the reporting requirements with the Child Nutrition staff and will review monthly claims for submission.

View Audit 6442

Finding 4084 (2023-003)

None 2023

Madison County School District No. 2, Norfolk Public Schools

NE

Cash Management Internal Control / Segregation of Duties

The District will maintain original invoices for supporting documentation for grant reimbursements submissions.

View Audit 6410

Finding 4083 (2023-002)

Significant Deficiency 2023

Madison County School District No. 2, Norfolk Public Schools

NE

Cash Management

The District will maintain supporting documentation to substantiate all transactions.

View Audit 6410

Finding 4048 (2023-003)

None 2023

Newbury Elderly Housing, Inc.

NH

Subrecipient Monitoring Cash Management

Plan: The Housing Director will monitor all major maintenance projects to ensure they are completed in a timely manner even with turnover at the project level. Anticipated Completion: December 31, 2023 (ongoing) ...

Plan: The Housing Director will monitor all major maintenance projects to ensure they are completed in a timely manner even with turnover at the project level. Anticipated Completion: December 31, 2023 (ongoing) Contact: Duska Noel, Director of Housing Michael Tabory, Chief Operating Officer

View Audit 6374

Finding 4022 (2023-003)

Material Weakness 2023

Shepherd Public School District

MI

Cash Management School Nutrition Programs Material Weakness

Finding Number 2023-003 — Excess in Food Service Fund — Repeat Finding - Material Weakness in Internal Control/Noncompliance — Special Tests and Provisions Condition: As of year-end, June 30, 2023, the district had a fund balance in the food service fund in excess of three months operating expenses ...

Finding Number 2023-003 — Excess in Food Service Fund — Repeat Finding - Material Weakness in Internal Control/Noncompliance — Special Tests and Provisions Condition: As of year-end, June 30, 2023, the district had a fund balance in the food service fund in excess of three months operating expenses by approximately $ 268,411. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: June 30, 2024 Corrective Action: The district has filed a spend down plan with the State of Michigan. This plan includes increasing labor costs for the operation of a kitchen at Winn Elementary School. Additionally, the district will purchase much needed new equipment. Sincerely Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 3983 (2023-001)

None 2023

Carolina College of Biblical Studies

NC

Student Financial Aid Cash Management Reporting

The Vice President of Finance corrected the disbursement dates for the students in question in September 2023. Going forward, the Student Financial Aid Office and Business Office will coordinate the drawdown of funds, reporting to COD, and posting to student accounts. The personnel of the College un...

The Vice President of Finance corrected the disbursement dates for the students in question in September 2023. Going forward, the Student Financial Aid Office and Business Office will coordinate the drawdown of funds, reporting to COD, and posting to student accounts. The personnel of the College understands that while on the cash advance method to disburse funds, they have three business days from the date the funds are received to post the funds to the student accounts. However, the disbursement date on the student account and in COD still must agree. Anticipated Completion Date: The corrective action was completed in September 2023. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614

View Audit 6283

Finding 3942 (2023-001)

Significant Deficiency 2023

Lutheran Family Services of Virginia, Inc. Dba Encircle

VA

Questioned Costs Cash Management Reporting

Department of Health and Human Services Lutheran Family Services of Virginia, Inc. and Subsidiaries d/b/a enCircle respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. ...

Department of Health and Human Services Lutheran Family Services of Virginia, Inc. and Subsidiaries d/b/a enCircle respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, Virginia 24018 Audit Period: Year ending June 30, 2023 The finding from the June 30, 2023 schedule of findings and questioned costs is discussed below. Findings – Financial Statement Audit NONE. Findings – Federal Award Programs Audits Department of Health and Human Services 2023-001: Unaccompanied Alien Children – ALN #93.676, Activities Allowed/Unallowed; Allowable Costs and Period of Performance and controls over Activities Allowed/Unallowed; Allowable Costs and Period of Performance. Significant Deficiency Criteria and Condition: Under the requirements of the Uniform Guidance, the drawdown of federal funds must be based on actual expenditures incurred. Context: We tested twenty-five reimbursed amounts from various awards. We noted two instances where the Organization obtained federal funds without incurring the actual expenditure. We also noted one instance where the expenditure occurred outside of the budget period. Cause: The Organization did not properly allocate expenditures within their general ledger and did not have an adequate review process in place. Effect: The lack of an adequate review process can cause federal funds to be obtained prior to the actual expenditure is incurred. Recommendation: We recommend that the Organization develop a review process to ensure the drawdown of federal funds does not occur before funds are expended and that the Organization submit expenditures incurred in the budget period. Action Taken: Management has implemented enhanced review processes to ensure the drawdown of Federal funds does not occur before funds are expended and that enCircle submits only expenditures incurred during the budget period. Name of Contact Person: David Pruett, Chief Financial Officer

View Audit 6220 Questioned Costs: $1

Finding 3932 (2023-004)

Significant Deficiency 2023

Presentation College

SD

Internal Control / Segregation of Duties Questioned Costs Student Financial Aid

Finding 2023-004 Cash Management –Reconciliations (Direct Loan) Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 – Federal Direct Student Loans Finding Summary: When testing cash management related to reconciliations, the auditors noted 2 of the ...

Finding 2023-004 Cash Management –Reconciliations (Direct Loan) Federal Agency Name: Department of Education Program Name: Student Financial Aid Cluster CFDA # 84.268 – Federal Direct Student Loans Finding Summary: When testing cash management related to reconciliations, the auditors noted 2 of the 12 monthly SAS reconciliations were not completed. Responsible Individuals: Jillaine Smith, Chief Operating Officer, Erin Drew, Facilitator of Advancement Services and Patty Pietz, Presentation Sisters Accountant. Corrective Action Plan: The Student Financial Aid Director completed a final reconciliation after final disbursements were made to students to ensure all aid awards was correctly reflected. Anticipated Completion Date: September 30, 2023

View Audit 6218

Finding 3878 (2023-001)

None 2023

Laramie Square Housing

WY

HUD Housing Programs Cash Management

Action Taken: Management agrees and will make up the deficient deposit as soon as possible.

View Audit 6126

Finding 3861 (2023-001)

None 2023

Voami Independence House of Detroit, Inc. (oak Village)

LA

Cash Management HUD Housing Programs

Management agrees with the finding. The residual receipts account deficiency was funded on February 27,2023 in the amount of $5,787. Management will ensure that the residual receipts account is properly funded in the future.

View Audit 6090

Corrective Action Plans

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