Corrective Action Plans

Finding 574079 (2024-001)

Material Weakness 2024

Chippewa County

MN

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

Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to ...

Finding Number: 2024-001 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Jennifer Bakkelund, Fiscal & Support Services Supervisor Corrective Action Planned: Due to overlap of when we found the errors from 2023 and the corrections of those in 2024, this triggered other areas we knew would have to change in 2024. This included more movement in personnel expenses for programs not considered under federal financial participation. These programs were all removed from the Family Services budget by January 1, 2025. The corrections to our internal systems were corrected in 2025. Chippewa County staff will connect with DHS to review the corrections made in our system as it pertains to the quarterly reports and will adjust as they instruct. For the Administrative split being used each year, we will use the A87 Report to determine the rate. It will be shared with the Payroll department, the County Auditor/Treasurer’s department and Family Services accounting staff prior to the start of the year or prior to any mid-year change. More oversight will be given to placement of “Other” charges that are paid in County systems and to make sure placement of those are correct in the quarterly reports. Anticipated Completion Date: December 2025

View Audit 364657

Finding 574078 (2024-002)

Material Weakness 2024

Village of Blanchardville

WI

Material Weakness Reporting Internal Control / Segregation of Duties

Finding #2024-002- Material Adjustments Condition: Johnson Block and Company, Inc. proposed adjusting journal entries during the audit process. We deem these entries to be material in relation to the financial statements. Since the Village did not make these adjustments in its accounting system pri...

Finding #2024-002- Material Adjustments Condition: Johnson Block and Company, Inc. proposed adjusting journal entries during the audit process. We deem these entries to be material in relation to the financial statements. Since the Village did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the Village’s internal controls. Criteria: Material adjusting journal entries not prepared by the Village before the audit are considered an internal control weakness. Cause: The Village does not have policies and procedures in place to ensure that all transactions are properly recorded on the general ledger prior to the audit. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The Village will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditor. Contact Person: Amy Barnes, Village Clerk/Treasurer, 608-523-4521, Email: clerk@blanchardvillewi.gov Anticipated Completion: December 31, 2025

View Audit 364647

Finding 574077 (2024-001)

Material Weakness 2024

Village of Blanchardville

WI

Internal Control / Segregation of Duties HUD Housing Programs

Finding #2024-001- Segregation of Duties Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional err...

Finding #2024-001- Segregation of Duties Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Cause: Limited number of personnel. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Recommendation: We recommend that the Village consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with the finding but do not believe it is cost-effective to increase the office staff in an attempt to bring about a more effective segregation of duties. Contact Person: Amy Barnes, Village Clerk/Treasurer, 608-523-4521, Email: clerk@blanchardvillewi.gov Anticipated Completion: Not Applicable

View Audit 364647

Finding 574071 (2024-003)

Significant Deficiency 2024

Housing and Redevelopment Authority of the City of Worthington

MN

HUD Housing Programs Internal Control / Segregation of Duties

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will monitor claims approvals going forward. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensu...

Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The HRA will monitor claims approvals going forward. Official Responsible for Ensuring CAP: Tanner Rogers, Executive Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The Board will be monitoring this corrective action plan and believes the Executive Director will remedy this finding.

View Audit 364640

Finding 574054 (2024-005)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.403 § 200.412

• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review firs...

• CFO will examine feasibility of adding flags to journal entries to ensure unallowable costs are flagged at the point of entry Will conduct training on allowable vs. unallowable costs Grants Accountant will conduct quarterly review of costs to ensure no unallowable costs included – will review first three months of FY26 by 12/31/25

View Audit 364634

Finding 574053 (2024-004)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy

View Audit 364634

Finding 574052 (2024-003)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.510 § 200.518

COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify th...

COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify the federal nature of all awards and stay current on SEFA and Uniform Guidance

View Audit 364634

Finding 574046 (2024-002)

Significant Deficiency 2024

City of Dover

NH

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.303

When submitting SLFRF Project & Expenditure Report, the City will break out expenditures into more detailed groupings of closely related activities. Past reports were submitted as one project which falls under SLFRF 6-Revenue Replacement 6.1-Provisions of Government Services.

View Audit 364631

Finding 574019 (2024-002)

None 2024

Housing Initiatives, INC

WI

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...

2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025

View Audit 364605

Finding 574016 (2024-003)

Significant Deficiency 2024

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD guidelines require Project cash to be maintained in financial institutions, which meet minimum GNMA ratings, when balances exceed federal insurance limits. Condition: The Organization maintains cash balances in excess of federally insured limits in a financial institution that does not meet HUD guidelines. Questioned costs: None Context: The cash balance as of December 31, 2024 was approximately $740,000, held in two financial institutions, which exceeded federal insurance limits by approximately $470,000. Cause: As the Organization is a community based non-profit organization, management considers supporting a local bank to be a worthwhile endeavor. Effect: No negative effect was discovered during the audit. Repeat Finding: No. Recommendation: The Organization should transfer all funds to a financial institution that meets HUD guidelines. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevins mission in the community. Given Nevins current financial struggles, the balance in the bank seldom exceeds the $250,000.00 threshold.

View Audit 364597

Finding 574014 (2024-002)

Significant Deficiency 2024

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires the Organization to make mortgage payments on a timely basis. Condition: Mortgage payments for February, March, April and May 2024 were not received by the mortgage company promptly. Questioned costs: None Context: February, March, April and May 2024 mortgage payments were received by the mortgage company subsequent to the 15th of the following month, which is considered late per HUD guidelines. Cause: Mortgage payments were being funded with approved withdrawals from reserve accounts which delayed timing of payment. Effect: Late charges were assessed to the Project. Repeat Finding: No. Recommendation: Mortgage payments should be made by the due date. Action Taken: Nevins was in touch with HUD monthly and developed a repayment plan but could not follow through. Nevins engaged with Alliance Healthcare for Accounts Receivable assistance in the fall of 2024 and then entered into a Management agreement with Alliance Healthcare in June of 2025.

View Audit 364597

Finding 573967 (2024-001)

Significant Deficiency 2024

Old Pueblo Community Services

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.

View Audit 364575

Finding 573938 (2024-002)

Material Weakness 2024

Lamoni Community School District

IA

Reporting Internal Control / Segregation of Duties

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We ...

The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing. The District does recognize this is difficult with a limited number of employees. We will continue to review our procedures to best meet the needs of the District as well as have internal control in place. We will work on dividing out duties and responsibilities so no one person is handling all cash, receipts, and financial transactions without checks & balance in place. A Business Office employee will collect cash and count, and another person will create the deposit slip, with a 3rd person (front office secretary) taking the actual deposit to the bank. Then the Business office employee will be the one responsible for entering the cash receipt into Software.

View Audit 364567

Finding 573907 (2024-001)

Material Weakness 2024

Sicangu Oyate Ho, INC

SD

Procurement, Suspension & Debarment Cash Management Material Weakness

Management Response: Our CPA will train our Accounting Tech to complete bank reconciliations. A huge part of the GL not being updated is due to credit card expenditures and not utilizing the software to update when there is credit card usage. We will begin using the School Accounting Software to tra...

Management Response: Our CPA will train our Accounting Tech to complete bank reconciliations. A huge part of the GL not being updated is due to credit card expenditures and not utilizing the software to update when there is credit card usage. We will begin using the School Accounting Software to track credit card expenditures so we won't have to wait until we get credit card statements to reconcile. Anticipated Completion Date: September 30, 2025 - we will begin utilizing the credit card feature in the Accounting Software immediately. Responsible Party: Accounts Payable Personnel; Accounting Tech will work with CPA's ; Business Manager will have oversight for completion.

View Audit 364557

Finding 573883 (2024-006)

Significant Deficiency 2024

Northern Lakes Community Mental Health

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Segregation of Duties

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Name of Contact Person: Chelsey Traeger, City Clerk

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 364494

Finding 573840 (2024-001)

Significant Deficiency 2024

Central Tribes of the Shawnee Area, Inc.

OK

Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328

Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.

View Audit 364487

Finding 573825 (2024-013)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573823 (2024-010)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573792 (2024-003)

Significant Deficiency 2024

Catahoula Parish School Board

LA

Eligibility Internal Control / Segregation of Duties

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Depar...

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I 84.010A 2024 Criteria or specific requirement: Title I, Part A of the Elementary and Secondary Education Act of 1965, as amended by Every Student Succeeds Act, requires eligibility to be determined based on the number of children ages 5 through 17 from low-income families. School Board management is required to review all total 118 Corrective Action Plan for Current Year Findings and Questioned Costs (Continued) For the Year Ended June 30, 2024 119 enrollment and low-income families’ data to ensure that the underlying data includes only students ages 5 through 17 and to certify that the eligibility calculations are complete and accurate. Condition found: Title I management completes and submits the Title I Targeting online to the Louisiana Department of Education (LDOE). The LDOE pre-populates the enrollment and number of low-income students in the Title I Targeting; however, these numbers are required to be reviewed and changed, if necessary, by the School Board. In reviewing the underlying data in determining eligibility for each school, it was noted that the School Board did not remove those students under age 5, which resulted in the ranking of schools to not be accurate. Corrective action planned: The School Board was unaware of the data file used needed to be reviewed; however, we will only include the accurate age band moving forward.

View Audit 364457

Finding 573785 (2024-005)

Material Weakness 2024

Catahoula Parish School Board

LA

School Nutrition Programs Cash Management Reporting

Reference # and title: 2024-005 Controls and Compliance over Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Titl...

Reference # and title: 2024-005 Controls and Compliance over Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I 84.010A 2024 COVID-19 Education Stabilization Funds: Education Stabilization (ESSER II) 84.425D 2021 Education Stabilization (ESSER III) 84.425U 2021 United States Department of Agriculture; passed through Louisiana Department of Education Child Nutrition Cluster: School Breakfast Program 10.553 2024 National School Lunch Program 10.555 2024 Criteria or specific requirement: Good internal controls require that all requests for reimbursement submitted to the Louisiana Department of Education (LDOE) are adequately reviewed and approved either before submission or after submission, but in a timely manner, to ensure amounts reported are complete and accurate. Condition found: In testing a sample of a requests for reimbursements for the Child Nutrition Program and periodic expense reports for the Title I and ESSER programs the following was noted: Title I: Total expenditures per the general ledger did not agree to the amounts reported in the final periodic expense report, which resulted in the School Board over requesting $71,386. It was also noted there is no review and approval process by a second person over the periodic expense report submissions. Child Nutrition: Although there were no exceptions noted in the information submitted to LDOE, it was noted there is no review and approval process by a second person over the claims for reimbursement. Education Stabilization: Total expenditures per the general ledger did not agree to the amounts reported in the fiscal year end’s periodic expense report submission. It was also noted that the School Board had over requested $118,103 in the current fiscal year. There is no review and approval process by a second person over the periodic expense report submissions. In testing the special reporting for the ESSER program, it was noted that the School Board had not maintained the supporting documentation for this report and therefore could not be adequately tested. Corrective action planned: The School Board will correct this immediately. We were aware of the Title I and ESSER issues and had been in contact with LDOE to correct them. We were unaware of Child Nutrition needing someone to review and approve those claims; however, we will implement that requirement moving forward.

View Audit 364457

Finding 573782 (2024-001)

Significant Deficiency 2024

Commonwealth Institute of Funeral Service

TX

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...

Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.

View Audit 364456

Corrective Action Plans

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