Corrective Action Plans

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2023-002 Significant deficiency Name of contact person: Michelle Raymond, Management Agent Corrective Action: The Organization will ensure that future certification notifications are sent to tenants within the prescribed 75-90 timeframe and will ensure that files are maintained intact for a min...
2023-002 Significant deficiency Name of contact person: Michelle Raymond, Management Agent Corrective Action: The Organization will ensure that future certification notifications are sent to tenants within the prescribed 75-90 timeframe and will ensure that files are maintained intact for a minimum of three years. Proposed implementation date: The corrective action plan will be implemented immediately.
District will work with legal counsel to establish parameters to execute verification for cause as outlined in USDA Food and Nutrition Services, Child Nutrition Programs Eligibility Manual for School Meals - Determining and Verifying Eligibility, Section 6 - Verification. District will work within e...
District will work with legal counsel to establish parameters to execute verification for cause as outlined in USDA Food and Nutrition Services, Child Nutrition Programs Eligibility Manual for School Meals - Determining and Verifying Eligibility, Section 6 - Verification. District will work within established parameters to verify district employee salaries of approved applications submitted by district employees
Finding 387726 (2023-003)
Significant Deficiency 2023
DEPARTMENT OF TREASURY 2023-003 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend management ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls...
DEPARTMENT OF TREASURY 2023-003 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend management ensure policies and procedures include the three options for determining suspension and debarment status listed in 2 CFR 180.300 and that controls are sufficient to ensure that the suspension and debarment status is verified for all vendors prior to issuance of the contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will ensure all new vendors will sign a suspension and debarment agreement prior to any payments being made. Name(s) of the contact person(s) responsible for corrective action: Kelly Baldwin, Director of Finance Planned completion date for corrective action plan: March 31, 2024 If the Cognizant or Oversight Agency has questions regarding this plan, please call Kelly Baldwin, Director of Finance at 410-239-3200.
This finding is listed as a repeat finding on Technical Errors cited finding in previous audit 2021-002. The primary root causes of these findings were due to extreme staffing shortage in each unit and having inexperienced staff. Extreme staffing shortages have been a constant battle that Lenoir Cou...
This finding is listed as a repeat finding on Technical Errors cited finding in previous audit 2021-002. The primary root causes of these findings were due to extreme staffing shortage in each unit and having inexperienced staff. Extreme staffing shortages have been a constant battle that Lenoir County has faced. The number of workers only consisted of a maximum of two workers to complete case actions for a normal staff unit of seven. The work increase has caused a significant impact on this unit, but the staff, lead workers, and supervisors make every effort to complete case actions in a timely manner. New staff members have been added but all are in training and have only been able to provide minimum assistance until training has been completed. Several trainings, staff meetings, and conferences have been conducted to streamline these errors and ensure that workers are applying policy to case actions correctly. Lenoir County will continue to implement the strategies and plan that ultimately works, and we strive for perfection in all actions that we complete, however, these steps will continue to be contingent upon maintaining the required staff and training staff to meet the accuracy level. Maintain the required accuracy standards rate of 96.8% or higher when determining eligibility for case actions, approvals, terminations and denials. Provide staff with the knowledge of the audit information, the performance improvement plan and what staff expectations are. Staff Meetings to be held November 15, 2023 to address audit findings and to start training process for staff to obtain knowledge needed to remain in compliance with policy standards. Run log reports on case actions completed by IMC workers and randomly complete three or more 2nd party reviews per day. Complete 100% 2nd party reviews on all new workers and pull findings within month of completion. New workers should be released from 100% 2nd party review process listed above when accuracy rating meets 98% for three consecutive months. Lead Workers turn in 2nd party reviews at least once per week or twice a week to be evaluated for error trends. Error trend reports are compiled by Lead Worker Supervisor and turned in monthly to Economic Services Administrator. Meetings held with Lead Workers, Medicaid Supervisors, Staffe Development Specialist and Administrator to evaluate error trends. Monthly trainings held, as needed, to review error trend findings of 2nd part reviews completed with staff. Proposed completion date for a policy compliance will start immediately and goal completion is set for February 1, 2024. Trainings conducted to remedy policy misinterpretations, by conducting monthly meetings, one-on-one conferences, and completion of remedial testing wither through the Learning Gateway or unit created tests.
This finding is listed as a repeat finding from the previous audit 2022-001 for eligibility determination. The training plan and fiscal controls for Lenoir County is a solid plan that works. However, no plan can be fulfilled and completed 100% successfully without staff to implement the desired goal...
This finding is listed as a repeat finding from the previous audit 2022-001 for eligibility determination. The training plan and fiscal controls for Lenoir County is a solid plan that works. However, no plan can be fulfilled and completed 100% successfully without staff to implement the desired goals. The Corrective Action Plan from prior audit stated that the Ex Parte reports would be monitored and reviewed by Lead Workers and Supervisors to ensure that the reviews are being completed within 30 days of receipt. Lenoir County has not changed the plan and the Lead Workers were submitting Ex Parte reviews to workers and providing a copy of report to supervisors to review. Lenoir County has been diligent in trying to remedy this problem and comply with agency, state and federal guidelines to process these actions in a timely manner. However, based on the current audit, it has been discovered that a report was being overlook and not monitored. The Lead Worker was completing one report and was distributing the information to workers; however the full report was not being assessed. Based on this assessment and the learned knowledge that this report was not being managed, the following steps have been implemented to ensure that the Lenoir County is brought up to standard. Lead Workers were instructed to print out reports and work the reports to bring the current list up to date immediately. Proposed completion date for compliance is January 1, 2024. Lead Workers will pull all the SSI Ex Parte reports (3) from th NCFAST system weekly and manage these reports effectively. Lead Worker will either complete or assign Ex Parte reviews to staff for completion. Supervisors receive lists from the Lead Worker showing the number of Ex Partes assigned to each worker and reviews must be checked each week when appliacation pending logs are also turned into the supervisor each week. Lead Workers and Supervisor are to check off the Ex Partes as being completed and monitor worker reports to ensure that the Ex Partes are being completed within in th erequired guidelines. Lead Worker must turn i Ex Parte report to the supervisor each month to verify completion of reports.
Name of contact person: Katie Langan Corrective action: With respect to the finding relating to program length issues, the College agrees with this finding and will make appropriate changes to ensure that the NSLDS records for program length are based on years, correcting the earlier issue of basin...
Name of contact person: Katie Langan Corrective action: With respect to the finding relating to program length issues, the College agrees with this finding and will make appropriate changes to ensure that the NSLDS records for program length are based on years, correcting the earlier issue of basing program length by weeks. With respect to the program change date record retention issue, the College agrees with this finding and will take appropriate actions to correct this issue. These actions will include retraining of staff to reinforce the necessity of retaining the records, providing adequate secure storage facilities for paper records and conducting regular quality control exercises to ensure that this issue does not re-occur. Proposed completion date: June 30, 2024
Finding 2023-002 Eligibility Auditee's Response and Planned Corrective Action The Authority has had staff and consultant turnover during the 2022 audit period. Additionally, the eviction moratorium and lasting effects from the COVID-19 pandemic have resulted in delayed or nonexistent response from ...
Finding 2023-002 Eligibility Auditee's Response and Planned Corrective Action The Authority has had staff and consultant turnover during the 2022 audit period. Additionally, the eviction moratorium and lasting effects from the COVID-19 pandemic have resulted in delayed or nonexistent response from tenants regarding obtaining the necessary documentation for eligibility requirements. The Authority has evidentiary documentation supporting their attempts to obtain the required documents from the tenants, including certified letters. The courts suspended evictions during the eviction moratorium that resulted from the COVID-19 pandemic, which includes evictions for nonpayment and noncompliance. The Authority has been working with legal counsel on these matters and continues to pursue this vigorously. The Authority's staff and consultants have been diligently working to implement improvements to the administrative systems related to recertifications. Additionally, the Authority has put in place a checklist for occupancy documents that are reviewed during recertification and when processing new tenants that must have annotations, check mark, that confirm that all required papers are in compliance and signed where appropriate. This check list will have at least one redundant review by the Authority's directors or designee. Planned Implementation Date of Corrective Action: March 2024 Person Responsible for Corrective Action: Keith Burrell, Executive Director
TRIO Upward Bound has new leadership from the Director up to the Vice President. The new Director has already implemented a new set of protocols to verify all eligibility markers are met. The Director's supervisor, the Dean of Equity and Inclusion, will conduct a spot check twice annually. Contact ...
TRIO Upward Bound has new leadership from the Director up to the Vice President. The new Director has already implemented a new set of protocols to verify all eligibility markers are met. The Director's supervisor, the Dean of Equity and Inclusion, will conduct a spot check twice annually. Contact person(s) responsible for corrective action: Jimmie Sanders, Director TRIO Upward Bound and Desiree Anderson, Dean of Equity and Inclusion. Anticipated Completion Date: Immediate
Contact Person: Interim Executive Director Fred Bazemore Corrective Action: The Organization agrees with the finding and is working to establish a clear understanding of the grant eligibility requirements with the grant coordinators to ensure eligibility requirements for the Uniform Guidance are fol...
Contact Person: Interim Executive Director Fred Bazemore Corrective Action: The Organization agrees with the finding and is working to establish a clear understanding of the grant eligibility requirements with the grant coordinators to ensure eligibility requirements for the Uniform Guidance are followed. Anticipated Completion Date: This corrective action will be implemented by June 30, 2024.
Finding 387414 (2023-003)
Significant Deficiency 2023
Finding Summary: Change, Inc. has an internal control process designed to review and sign the eligibility forms, but the controls did not operate as designed. Personnel at Change Inc. Were unable to produce documentation supporting the review of participant files for participant eligibility. Respo...
Finding Summary: Change, Inc. has an internal control process designed to review and sign the eligibility forms, but the controls did not operate as designed. Personnel at Change Inc. Were unable to produce documentation supporting the review of participant files for participant eligibility. Responsible Individuals: Jill Johnson, Associate Director Corrective Action Plan: We are working to formalize this process by creating a written participant file review policy and procedure. Anticipated Completion Date: March 31, 2024
Contact Person: Cynthia McCarthy, Director of Financial Aid Corrective Action: For the 2023-2024 academic year Cost of Attendance Budgets were reviewed and tested to correct any miscalculations and omissions. Pell Budgets were updated to correctly differentiate program tuition and fees. Testing for ...
Contact Person: Cynthia McCarthy, Director of Financial Aid Corrective Action: For the 2023-2024 academic year Cost of Attendance Budgets were reviewed and tested to correct any miscalculations and omissions. Pell Budgets were updated to correctly differentiate program tuition and fees. Testing for 2024-2025 academic year has been updated and reviewed to accurately calculate Cost of Attendance Budgets. In some of the findings it was later found that due to changes made in the student’s record, the record should have run through the dynamic redetermination process to update the budget. The staff has been retrained in this process. The process for summer periods of enrollment has been reviewed and revised to flag students who initially applied and or registered for summer classes and subsequently did not register or dropped the classes during the add/drop period and the summer period of enrollment remained thereby calculating a Cost of Attendance for summer. Anticipated Completion Date: January 3, 2024
Ineligible Programs Planned Corrective Action: Additional training regarding program eligibility has been conducted with the Processing Team. Previously unknown functionality to designate a program as being ineligible for Title IV aid in the Colleague administrative system was identified and implem...
Ineligible Programs Planned Corrective Action: Additional training regarding program eligibility has been conducted with the Processing Team. Previously unknown functionality to designate a program as being ineligible for Title IV aid in the Colleague administrative system was identified and implemented. Title IV funds can no longer be disbursed for programs marked as ineligible. Person Responsible for Corrective Action Plan: Bryan Taylor, Associate Director of SFS Processing Anticipated Date of Completion: February 2024
View Audit 299440 Questioned Costs: $1
2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063...
2023-004 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Condition: We examined 40 student files and we noted one student was not properly awarded their Pell grant. We consider this condition to be an instance of noncompliance relating to the Eligibility compliance requirement. Management Response: This was a student transferring from a college that had closed (Lincoln College) the Financial Aid staff did not calculate new PELL eligibility with the Eureka College COA and awarded Pell from the wrong matrix on the Pell payment chart. Corrective Action Plan: All pell awards are now being offered based on correct COA and Pell Grant matrix with the Eureka costs. Responsible Person: Tim Marten, Director of Financial Aid Implementation Date: Spring 2024
2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063...
2023-003 – Student Financial Aid Cluster – (a) Federal Pell Grant (b) Federal Supplemental Educational Opportunity Grant (c) Federal Work Study Grant (d) Federal Perkins Loan Program (e) Federal Direct Student Loans (f) Teacher education Assistance for College and Higher Education ALN No. (a) 84.063 (b) 84.007 (c) 84.033 (d) 84.038 (e) 84.268 (f) 84.379 – Year Ended June 30, 2023 Condition: We examined 40 student files and we noted 3 out of 40 students were not properly awarded Direct Loans. One of these students was improperly awarded subsidized loans and instead should have received unsubsidized loans. Additionally, the College did not report actual loan disbursement dates to the Common Origination and Disbursement (COD) system for 1 of the 40 students in the sample (2.5%). We consider these conditions to be instances of noncompliance in internal control over compliance relating to the Eligibility compliance requirement. Management Response: Cost of Attendance (COA) calculations were not updated to ensure ratio of subsidized versus unsubsidized loans were correct. It looks like awards were not being recalculated as additional need based aid was added to awards for these students. Corrective Action Plan: New financial aid software (JFA) was implemented for the 2023-2024 academic year. A component of this software is a compliance check for COA and other issues. The compliance check for over awards should catch instances of the wrong sub/unsub ratio in the future. Responsible Person: Tim Marten, Director of Financial Aid Implementation Date: Fall 2023
View Audit 299424 Questioned Costs: $1
2023-002 Eligibility Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P130272 (7/1/2022 - 6/30/2023), P268K130272 (7/1/2022 ...
2023-002 Eligibility Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P130272 (7/1/2022 - 6/30/2023), P268K130272 (7/1/2022 - 6/30/2023) Contact Person: Jean McDonald Rash, AVP Enrollment Services, 848-932-2605 Corrective Action: In order to correct the issue of students being awarded in excess of their cost of attendance, a weekly report has been developed to capture any student whose financial aid, from any source, exceeds the assigned cost of attendance. The Financial Aid Processing team in University Enrollment Services receives and resolves the issues in the report weekly to ensure that students are not awarded in excess of their assigned cost of attendance. In order to correct the issue of the incorrect calculation of the cost of attendance components, a testing plan has been developed that includes manually checking each program cost of attendance prior to signing off for production aid packaging. The script that caused the cost of attendance components to be doubled was corrected prior to the 2023-2024 aid year. Anticipated Completion Date: Completed
View Audit 299417 Questioned Costs: $1
CContact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – December 29, 2023
CContact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures to ensure all students who receive a free or reduced meal have a current and accurate application on file. Completion Date – December 29, 2023
Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures for verifying free and reduced applications. Completion Date – December 29, 2023
Contact Person – Thomas A. Jerome, Superintendent Corrective Action Plan – The District will implement policies and procedures for verifying free and reduced applications. Completion Date – December 29, 2023
Finding 387073 (2023-001)
Significant Deficiency 2023
The City has taken action by updating the procedures to now include a requirement for attaching the suspension and debarment verifications as part of the documentation process.
The City has taken action by updating the procedures to now include a requirement for attaching the suspension and debarment verifications as part of the documentation process.
2023-006 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth and Adult Activities particip...
2023-006 Eligibility U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement policies and procedures to ensure that the necessary controls are in place to properly verify the eligibility of all Youth and Adult Activities participants. Action Taken: The Board’s Youth Liaison monitors the In School and Out of School Youth eligibility every six months following the policy and procedures referencing the CF200. The Board’s Youth Liaison reviews the Youth files to determine if the Youth meets the eligibility criteria for the Youth program. Her monitoring is reviewed every six months during the State Audit. The Board will review her monitoring along with copies of the completed registrations from the Board’s subrecipient which determines which program the youth (Youth In or Youth Out) is eligible for the fiscal year. The Board will state that they have reviewed the eligibility perimeters and these were followed by the subrecipient and verified by the Youth Liaison. For the Adult Program, the Board has implemented internal controls to ensure each applicant completes the applications and to determine if they are eligible for the programs the Board offers. Our Business Services Manager reviews each application taken by the Board’s Career Services Coordinator and ensures they are in the correct program by the application.
Finding 386998 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Personnel Responsible for Corrective Action: Senior Vice President, Student Experience – Joseph Sallustio Anticipated Completion Date: March 2024 Corrective Action Plan: The University has completed its implementation of Anthology, a student information system, during the 2023-...
Finding 2023-001 Personnel Responsible for Corrective Action: Senior Vice President, Student Experience – Joseph Sallustio Anticipated Completion Date: March 2024 Corrective Action Plan: The University has completed its implementation of Anthology, a student information system, during the 2023-2024 fiscal year. The new system has several built in features that are supplemented with internal controls to ensure financial aid is awarded correctly. The system automatically awards the student at full-time, the awards are then confirmed through a review process before sending out the award notification, and again before payment. The system compares the full-time award status with the actual enrollment and if they do not match the student will fail for payment and we will revise the award.
At the beginning of FY2024, under the terms of PHA's Recovery Agreement with HUD, PHA's consultants conducted PIH internal QCs and staffing assessments. As a result of those findings, PHA has reorganized and increased the PHA staff, with a new Public Housing Manager. Staff are being fully trained re...
At the beginning of FY2024, under the terms of PHA's Recovery Agreement with HUD, PHA's consultants conducted PIH internal QCs and staffing assessments. As a result of those findings, PHA has reorganized and increased the PHA staff, with a new Public Housing Manager. Staff are being fully trained regarding eligibility determinations and rent calculations, checklists are being developed and regular internal QCs performed, with an objective of full compliance by the end of calendar year 2024.
The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance. Following an internal SEMAP QC review in July 2023, staff have been retrained and certificat...
The finding of missing income verifications for eligibility and recertification rent calculations is being addressed as part of a holistic review under the Recovery Agreement of Section 8 program compliance. Following an internal SEMAP QC review in July 2023, staff have been retrained and certification/recertification checklists have been created. Initial and annual recertifications are currently being conducted in accordance with the applicable HUD regulations and guidance and will be internally reviewed during a July 2024 SEMAP QC review .
FINDING 2023-006 Subject: Title I Grants to Local Educational Agencies – Internal Controls Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A1900...
FINDING 2023-006 Subject: Title I Grants to Local Educational Agencies – Internal Controls Federal Agency: Department of Education Federal Program: Title I Grants to Local Educational Agencies Assistance Listing Number: 84.010 Federal Award Numbers and Years (or Other Identifying Numbers): S010A190014, S010A200014, S010A210014, S010A220014 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility, Reporting, Special Tests and Provisions - Assessment System Security Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Terri Chance Contact Phone Number and Email Address: 219-924-4250 tchance@griffith.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Griffith Public Schools will be developing, implementing, and documenting, a system of internal controls, including policies and procedures that provide segregation of duties to ensure appropriate reviews, approvals and oversight are taking place. Anticipated Completion Date: June 30, 2025
FINDING 2023-004 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.55...
FINDING 2023-004 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listings Numbers: 10.553, 10.555, 10.559 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Tiffiny Ulman Contact Phone Number and Email Address: 219-924-4250 tulman@griffith.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Establish post award internal controls surrounding grant management including, but not limited to, Eligibility. Anticipated Completion Date: 3/5/2024
U.S. Department of Health and Human Services Bullhook Community Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The findings from the schedule of findings and questioned costs are discuss...
U.S. Department of Health and Human Services Bullhook Community Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 through June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2023-001 Health Center Program Cluster Recommendation: Management should review their policies and procedures with the personnel responsible for providing the sliding fee discount and for ensuring that documentation is maintained to support the eligibility of sliding fee discount. We also recommend that management implement, monthly or quarterly, a self-audit process of newly approved sliding fee discount recipients and their associated patient record. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff were retrained on sliding fee policy and procedure. Going forward frequent audits from the sliding fee applications received and entered will be conducted to ensure that proper documentation is maintained. Name(s) of the contact person(s) responsible for corrective action: Kyndra Hall, CEO Planned completion date for corrective action plan: June 30, 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kyndra Hall, Chief Executive Officer at (406) 395-6904.
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