Corrective Action Plans

Finding 522118 (2024-002)

None 2024

MA

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Recommendation: Closer attention should be paid when preparing the requests for reimbursement to ensure only allowable expenses are being included in the request. A secondary review of the request and supporting documentation should be performed by someone other than the preparer. Action Taken: A de...

Recommendation: Closer attention should be paid when preparing the requests for reimbursement to ensure only allowable expenses are being included in the request. A secondary review of the request and supporting documentation should be performed by someone other than the preparer. Action Taken: A detailed checklist will be introduced to ensure all requests for reimbursement match supporting payroll documentation. This checklist will include a reconciliation step for timesheet data and payroll disbursement records. Staff involved in grant management and reimbursement preparation will receive additional instruction on federal compliance requirements, with a focus on allowable costs and activities.

View Audit 341337

Finding 522013 (2024-003)

Significant Deficiency 2024

Gale-Ettrick-Trempealeau School District

WI

Questioned Costs Cash Management Matching / Level of Effort / Earmarking

2024-003 – Education Stabilization Fund – Prevailing wage rate requirements Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages ...

2024-003 – Education Stabilization Fund – Prevailing wage rate requirements Criteria: Wage rate requirements apply to the Education Stabilization Fund when laborers and mechanics employed by contractors or subcontractors work on construction contracts more than $2,000. Laborers must be paid wages not less than those established for the locality of the project (prevailing wage rates) by the Department of Labor (DOL). Nonfederal entities shall include in their contracts, subject to wage rate requirements, a provision that the contractor or subcontractor comply with those requirements and the DOL regulations. This includes a requirement for the contractor or subcontractor to submit to the District weekly payrolls and a statement of compliance (certified payrolls). Condition: There was one Education Stabilization Fund construction project performed by a subcontractor. Grant expenditures for the project paid by the Education Stabilization Fund totaled $33,192. There was not a prevailing wage clause in the contract and certified payrolls were not received. Cause: The District was not aware that wage rate requirements applied to the construction project. Effect: A reimbursement request was made for expenditures that did not comply with wage rate requirements. Questioned Costs: $33,192 Auditor’s Recommendation: Establish controls to comply with wage rate requirements related to the Education Stabilization Fund. Management Response: The District will comply with the wage rate requirements for the Education Stabilization Fund going forward. Contact Person: Cary Brommerich Anticipated Completion: Not applicable

View Audit 341280 Questioned Costs: $1

Finding 521998 (2024-001)

Significant Deficiency 2024

Caritas Manor, Inc.

MS

Questioned Costs Special Tests & Provisions Cash Management

U.S. Department of Housing and Urban Development Caritas Manor, Inc., HUD Project No. 065-EE003-CA, respectfully submits the following corrective action plan for the year ended September 30, 2024. Audit Firm: McNorton Ishee & Jones, P.C. P.O. Box 161425 Mobile, Alabama 36616 Audit period: Sep...

U.S. Department of Housing and Urban Development Caritas Manor, Inc., HUD Project No. 065-EE003-CA, respectfully submits the following corrective action plan for the year ended September 30, 2024. Audit Firm: McNorton Ishee & Jones, P.C. P.O. Box 161425 Mobile, Alabama 36616 Audit period: September 30, 2024 Finding 2024-001 – Special Tests and Provisions State of Condition: The project has not made the required residual receipts deposit. Corrective Action: Management will ensure to make the required residual receipts deposit. If the Department of Housing and Urban Development should have any questions or comments regarding this plan, please contact Craig Bounds at (228) 435-1642.

View Audit 341227 Questioned Costs: $1

Finding 521249 (2024-001)

Significant Deficiency 2024

Langston University

OK

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.305

Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Questioned Costs: N/A Action taken in response to finding: This is a...

Recommendation: We recommend that the University review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Questioned Costs: N/A Action taken in response to finding: This is a repeat finding that was first presented to the University in conjunction with the release of the 2023 audit report in May 2024. The 2023 audit was completed after substantially all of Fiscal Year 2024 had elapsed, so there was not adequate time for the University to fully implement corrective action. The University is strengthening its accounts payable processes and sign-off approvals to help ensure reimbursements to subrecipients are paid timely. Principal investigators and designated administrative personnel within academic departments will be reminded of the need to initiate payments to subrecipients timely. Name(s) of the contact person(s) responsible for the corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration at Oklahoma State University and Mr. Chris Kuwitzky, Vice President for Fiscal and Administrative Affairs. Planned completion date for corrective action plan: March 2025

View Audit 341200

Finding 521200 (2024-004)

Significant Deficiency 2024

Clackamas County School District No.108

OR

Cash Management School Nutrition Programs Significant Deficiency

a. Significant Deficiency | Single Audit – “We recommend the District record reimbursements in the correct fiscal year.” b. Plan of Action – The District will establish a multi-step review process for all NSLP monthly meal claims to ensure accuracy. For the year-end claims (May/June) – should they b...

a. Significant Deficiency | Single Audit – “We recommend the District record reimbursements in the correct fiscal year.” b. Plan of Action – The District will establish a multi-step review process for all NSLP monthly meal claims to ensure accuracy. For the year-end claims (May/June) – should they be received after the end of the fiscal year they were claimed for – a journal entry that recognizes Accounts Receivable for the claim amount will be created and be reviewed for accuracy before being approved. c. Timeframe for (or date of) implementation – The multi-step review process for monthly NSLP meal claims has already been established (started in September 2024). The year-end journal entry process/review will be implemented in June 2025.

View Audit 341157

Finding 521196 (2024-003)

Significant Deficiency 2024

Clackamas County School District No.108

OR

Cash Management School Nutrition Programs Significant Deficiency

a. Significant Deficiency | Single Audit – “We recommend the District use someone other than the claim preparer to review the claims before being submitted, and document said review with initials and dates.” b. Plan of Actions – The District will establish a multi-step review process for all NSLP mo...

a. Significant Deficiency | Single Audit – “We recommend the District use someone other than the claim preparer to review the claims before being submitted, and document said review with initials and dates.” b. Plan of Actions – The District will establish a multi-step review process for all NSLP monthly meal claims to ensure accuracy. This process will include data input/review by the Nutrition Services Coordinator and review by the Director of Finance/Senior Accountant before submission to the state. c. Timeframe for (or date of) implementation - The multi-step review process for monthly NSLP meal claims has already been established (started in September 2024).

View Audit 341157

Finding 521185 (2024-006)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties Questioned Costs

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to e...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management.

View Audit 341140

Finding 521184 (2024-005)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties Questioned Costs

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc. will review their process for reviewing and approving reimbursement requests. Completion Date: The Center implemented an internal control in October 2023 to ensure all reimbursement reques...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc. will review their process for reviewing and approving reimbursement requests. Completion Date: The Center implemented an internal control in October 2023 to ensure all reimbursement requests are reviewed and approved by management.

View Audit 341140

Finding 521183 (2024-004)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties Questioned Costs

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to e...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management.

View Audit 341140

Finding 521182 (2024-001)

Significant Deficiency 2024

Housing Authority of Lake City

SC

HUD Housing Programs Questioned Costs Allowable Costs / Cost Principles

2024-001 ALN 14.871 – Housing Voucher Cluster – Activities Allowed or Unallowed The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Questioned Costs. In 2021, the Authority was instructed by Keith Landrum of the Colu...

2024-001 ALN 14.871 – Housing Voucher Cluster – Activities Allowed or Unallowed The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Questioned Costs. In 2021, the Authority was instructed by Keith Landrum of the Columbia, South Carolina HUD Field Office to stop making payments until the matter could be further investigated to see what amounts, if any, are still owed. Management will continue to monitor budgets to ensure that funds are adequate. Management has and will continue to make budget revisions to reduce unessential operating costs. The Authority has designed and implemented a Board approved formal repayment agreement. Person Responsible for Correction of Finding: Mark Fountain, Executive Director Projected Completion Date: June 30, 2025

View Audit 341129 Questioned Costs: $1

Finding 521157 (2024-003)

Significant Deficiency 2024

Hamilton Health Center, Inc.

PA

Questioned Costs Cash Management Allowable Costs / Cost Principles

Condition The Organization's negotiated indirect cost rate agreement includes a provisional rate of 17.75% of direct costs for the period April 1, 2021 through March 21, 2024. The Organization charged indirect costs to its American Rescue Plan supplemental health center funding using a rate of 18.8...

Condition The Organization's negotiated indirect cost rate agreement includes a provisional rate of 17.75% of direct costs for the period April 1, 2021 through March 21, 2024. The Organization charged indirect costs to its American Rescue Plan supplemental health center funding using a rate of 18.8% of direct costs for the period April 2023 through June 2023. The 18.8% rate that was used was obtained from an expired indirect cost rate agreement. Corrective Action Plan Corrective Action Planned: The continued use of the expired indirect cost rate was caused by the departure of the CFO who was responsible for reviewing federal grant draw downs. After the CFO left, the controller continued using the expired indirect cost rate but now the new CFO has put in place a system of review the indirect cost rate in effect against all reports before drawing down the grant. Name(s) of Contact Person(s) Responsible for Corrective Action: Frackson Sakala, CFO; Joseph McLaughlin, Controller; and Tran Le, the Assistant Controller. Anticipated Completion Date: This was immediately effected when this error was discovered during the FY2024 audit.

View Audit 341112 Questioned Costs: $1

Finding 521152 (2024-001)

None 2024

Big Brothers Big Sisters of Central Ohio, Inc. & Subsidiaries

OH

Questioned Costs Subrecipient Monitoring Cash Management

Finding Number: 2024-001 Condition: The Organization failed to submit monthly reimbursement requests to the Franklin County Department of Job and Family Services by their due dates during the year ended June 30, 2024. Planned Corrective Action: The Organization, effective the anticipated completio...

Finding Number: 2024-001 Condition: The Organization failed to submit monthly reimbursement requests to the Franklin County Department of Job and Family Services by their due dates during the year ended June 30, 2024. Planned Corrective Action: The Organization, effective the anticipated completion date cited in prior year CAP plan, 4/30/2024, has implemented system and process improvements to ensure timely submission. The Organization has and will continue to maintain appropriate staffing level and sufficient training to ensure timely submission. This plan does not account for circumstances beyond BBBSCO’s control such as timing of funding approval from Franklin County. Non-controllable delays will be documented by BBBSCO and reports submitted in a reasonable amount of time following approval. Contact Person Responsible for Corrective Action: Elizabeth Martinez, President and CEO Anticipated Completion Date: January 31, 2025

View Audit 341106

Finding 521110 (2024-001)

Material Weakness 2024

Deliverance Manor Housing Corporation

IL

Questioned Costs Student Financial Aid Cash Management

CORRECTIVE ACTION PLAN Finding No. 2024-001: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be pos...

CORRECTIVE ACTION PLAN Finding No. 2024-001: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be posted to the proper general ledger account. Action Taken or Planned: Credit card accounts will be reconciled and receipts will be requested for purchases. Accounting will review the nature of purchases and properly post to the general ledger. Responsible Person: Mary Amador, Property Manager Completion Date: October 31, 2024

View Audit 341047 Questioned Costs: $1

Finding 521078 (2024-001)

Significant Deficiency 2024

Gloucester County Special Services School District

NJ

Questioned Costs Cash Management Period of Performance

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The traini...

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The training will include but is not limited to: NJ Finance law, good business practice, as well as a review of the purchasing manual. After this training in completed, the business office will be responsible for the review of reimbursement requests, final reports, amendments and purchases, prior to completion and submission to ensure compliance with the grant requirements and purchasing laws.

View Audit 341013

Finding 521056 (2024-005)

Material Weakness 2024

Weld County School District Re-1

CO

Questioned Costs Subrecipient Monitoring Cash Management

Weld County School District RE-1 is a small rural district with limited personnel resources across the district including the Finance Department. The district worked to set up a formalized review process for grant budgets and expenditures charged to grants. The district was able to implement the pro...

Weld County School District RE-1 is a small rural district with limited personnel resources across the district including the Finance Department. The district worked to set up a formalized review process for grant budgets and expenditures charged to grants. The district was able to implement the process at the end of FY24. The district will continue to use and review this process and refine it through FY25 and FY26.

View Audit 340957

Finding 521055 (2024-001)

Significant Deficiency 2024

The Russell Child Development Center, Inc.

KS

Cash Management Eligibility Significant Deficiency

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimburse...

2024-001 Eligibility Condition Six providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that reimbursements are only requested for complete and accurate meal counts at the correct rate of reimbursement, and that only eligible participants 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 the date of this notice, CACFP staff will continue to 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. The Director of the CACFP program is now a third check for the tally marks matching what’s entered into My Food Program, as well as the totals claimed by the provider. Manual claim adjustments will continue to be saved and filed with supporting documentation, if applicable.

View Audit 340951

Finding 520911 (2024-002)

Significant Deficiency 2024

Wheeling Jesuit University INC

WV

Cash Management Student Financial Aid Internal Control / Segregation of Duties

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University has formalized and documented financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this has created a reasonable transition pla...

Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University has formalized and documented financial processes to establish internal controls in order to ensure accurate, timely and consistent reporting. In addition, this has created a reasonable transition plan during employee turnover, as well as ensures proper and timely filings. The corrective action involves drawing down the funds from the G5 federal website and issuing refunds to students that day. There is a checks and balance process built in so multiple staff members are involved with the process. The financial aid department calculates the amount of a federal drawdown and relays that information to the business department. The senior accountant draws down the appropriate amount of federal financial aid. The student accounts billing coordinator applies the aid to the various student accounts in the software. After the aid has been applied, the student accounts billing coordinator determines if a refund is due to the students. Any students that are entitled to a refund will be cut a refund check that day. The students will then have a window of opportunity of to come pick up the refund checks. Within two business days, any students who have not picked up their refund checks will have them mailed to their address on file with the University. This process has been developed to ensure that students receive their refunds in a timely and accurate manner. Anticipated Completion Date: February 2024

View Audit 340797

Finding 520887 (2024-002)

Material Weakness 2024

Lutheran Social Services of Central Ohio Kensington Place, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact per...

Condition: The Corporation did not deposit prior year surplus cash totaling $25,068 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340745

Finding 520886 (2024-002)

Material Weakness 2024

Ashland Assisted Living, Inc. D/b/a Lutheran Village of Ashland

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-002 Condition: The Corporation did not deposit prior year surplus cash totaling $56,345 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340744

Finding 520884 (2024-003)

Material Weakness 2024

Good Shepherd Real Estate Holding, LLC D/b/a the Good Shepherd

OH

HUD Housing Programs Internal Control / Segregation of Duties Cash Management

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Acti...

Finding Number: 2024-003 Condition: The Corporation did not deposit prior year surplus cash totaling $19,794 to the residual receipts account during the year ended June 30, 2024, which was calculated as of June 30, 2023, as required by the regulatory agreement and FRAG Guide. Planned Corrective Action: Corrected Contact person responsible for corrective action: Fikru Nigusse, CFO Anticipated Completion Date: N/A

View Audit 340743

Finding 520865 (2024-004)

Significant Deficiency 2024

Linden-Kildare Consolidated Independent School District

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the audit...

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the auditors and implement additional controls to monitor compliance with federal program guidelines.

View Audit 340692 Questioned Costs: $1

Finding 520834 (2024-007)

Significant Deficiency 2024

Alamance County, North Carolina

NC

Questioned Costs Cash Management Significant Deficiency

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and makin...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and making sure that information is accurate. Going forward supervisor will send out notification when IRS mileage reimbursement rates change and accounts payable staff will ensure the payable has the correct IRS mileage reimbursement rate listed. Proposed Completion Date: Immediate and ongoing.

View Audit 340657 Questioned Costs: $1

Finding 520753 (2024-003)

Significant Deficiency 2024

Central Cass Public School District

ND

Cash Management § 200.305

Contact Person: Pam Utt, Business Manager. Corrective Action Plan: Management recognizes the deficiency and plans to review the control process for how the District performs the drawdown. Management attributes the occurrence of the deficiency to unfamiliarity with the reporting mechanisms of the gra...

Contact Person: Pam Utt, Business Manager. Corrective Action Plan: Management recognizes the deficiency and plans to review the control process for how the District performs the drawdown. Management attributes the occurrence of the deficiency to unfamiliarity with the reporting mechanisms of the grant, which was new to the District during the period under audit, and feels confident such instances can be prevented in the future. Planned Completion Date for CAP: June 30, 2025.

View Audit 340477

Finding 520628 (2024-001)

Material Weakness 2024

Euclid City School District

OH

Cash Management Reporting Internal Control / Segregation of Duties

The Treasurer or designee will periodically, but not less than three times annually, conduct a review of the meal counts manually entered into the point of sale system and the CRRS and verify the counts entered manually into the CRRS system. Patrick Higley, Dawn Johnson, and Jim Fadel will be the pa...

The Treasurer or designee will periodically, but not less than three times annually, conduct a review of the meal counts manually entered into the point of sale system and the CRRS and verify the counts entered manually into the CRRS system. Patrick Higley, Dawn Johnson, and Jim Fadel will be the parties responsible for ensuring the accuracy of the counts.

View Audit 340291

Finding 520568 (2024-002)

Significant Deficiency 2024

Buncombe County, Nc

NC

Allowable Costs / Cost Principles Reporting Cash Management

2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires ...

2024-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires program salaries to be allocated and supported by payroll and attendance records for individuals. There is no disagreement with this audit finding.The County will develop and deliver day sheet training which will be required for all staff responsible for completing these reports. The County will also conduct random reviews monthly. Any discrepancies identified will be provided to staff leadership for support and correction. The County will implement additional reviews if errors are identified until corrections are made. New reporting will be created to track review findings and will be shared with the Quality and Performance Officer or their designee. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: 1/31/2025 – Day sheet training 3/1/2025 – Begin review of random of day sheets and timesheets 4/25/2025 – Report tracking of review findings

View Audit 340126

Corrective Action Plans

Filters