Corrective Action Plans

Finding 510794 (2024-004)

Material Weakness 2024

Phillips County Hospital Association

MT

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Management will establish and fund a segregated reserve account.

View Audit 329595

Finding 509781 (2024-001)

Significant Deficiency 2024

Realife Cooperative of Eau Claire

WI

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not applicable.

View Audit 329515

Finding 509777 (2024-001)

Significant Deficiency 2024

Durand Community Unit School District No. 322

IL

Internal Control / Segregation of Duties

The district will continue to have a second individual review all montly bank statements, reconciliations, and treasurer's reports. The district will continue to have the Payroll Bookkeeper review accounts payable checks prior to mailing them and maintain documenation of the checks that have been re...

The district will continue to have a second individual review all montly bank statements, reconciliations, and treasurer's reports. The district will continue to have the Payroll Bookkeeper review accounts payable checks prior to mailing them and maintain documenation of the checks that have been reviewed

View Audit 329504

Finding 509774 (2024-001)

Significant Deficiency 2024

E Center

CA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2024-001: No Access to Historical Payroll Timesheets Management’s Response Management recognizes the absence of access to historical payroll timesheets due to E Center's transition to a new payroll system as of January 1, 2024. Following the transition, access to the prior system was discont...

Finding 2024-001: No Access to Historical Payroll Timesheets Management’s Response Management recognizes the absence of access to historical payroll timesheets due to E Center's transition to a new payroll system as of January 1, 2024. Following the transition, access to the prior system was discontinued. E Center had arranged with the former payroll provider to supply all necessary documents; however, a former employee did not download the documents before the provided link expired. Although E Center understands the importance of this finding, we are confident that it was an isolated occurrence. Our current payroll system securely retains timecard data, and we have successfully provided all requested records since the January 1 implementation of the new service. Contact Person Responsible for Corrective Action: Karen Peters Anticipated Completion Date: January 1, 2024

View Audit 329490

Finding 509765 (2023-002)

Significant Deficiency 2024

Family Development Services, Inc.

IN

Reporting Internal Control / Segregation of Duties

FDS will modify our review process for valuing In-Kind. Additional monitoring of worksheets will be implemented. After the In-Kind Valuation worksheet is completed by the person responsible and submitted monthly to finance, there will be an additional monitoring review by finance of the In-Kind Valu...

FDS will modify our review process for valuing In-Kind. Additional monitoring of worksheets will be implemented. After the In-Kind Valuation worksheet is completed by the person responsible and submitted monthly to finance, there will be an additional monitoring review by finance of the In-Kind Valuation worksheets for accuracy. The Fiscal Year In-Kind Valuation worksheet will be reviewed by the Finance Director periodically and when updates and revisions occur. A written procedure will be developed to adhere to this Finding Corrective Action Plan.

View Audit 329458

Finding 509753 (2024-004)

Significant Deficiency 2024

Westfield Washington Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Significant Deficiency § 200.303

Finding 2024-004 – Child Nutrition Cluster – Special Tests and Provisions – Paid Lunch Equity Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action...

Finding 2024-004 – Child Nutrition Cluster – Special Tests and Provisions – Paid Lunch Equity Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The food service director will complete the Paid Lunch Equity spreadsheet, provide the spreadsheet and all supporting documents to the controller for review. Once approved, it will be submitted to the Indiana Department of Education. The supporting documents will either be scanned in or paper documents will be retained for future audit. Anticipated Completion Date: November 19, 2024

View Audit 329409

Finding 509745 (2024-002)

Material Weakness 2024

Westfield Washington Schools

IN

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Finding 2024-002 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The food service director will p...

Finding 2024-002 – Child Nutrition Cluster – Reporting Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The food service director will pull the End of Day Summary Reports from Lunchtime and input the information into the Child Nutrition Portal. All reports will be provided to the controller to confirm accuracy. Once reviewed and approved, the food service director will submit the report through the Child Nutrition Portal. All documents will be scanned together and be retained for audit. Anticipated Completion Date: October 2, 2024

View Audit 329409 Questioned Costs: $1

Finding 509741 (2024-001)

Material Weakness 2024

Westfield Washington Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2024-001 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: School corporation personnel w...

Finding 2024-001 – Child Nutrition Cluster – Eligibility Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: School corporation personnel will conduct an annual review of the income eligibility guidelines used by the food service software. The review will ensure that the guidelines are current, accurate, and consistent with federal and state requirements. The results of the review will be documented, and any necessary updates or changes will be implemented promptly. Anticipated Completion Date: November 13, 2024

View Audit 329409

Finding 509736 (2024-001)

Significant Deficiency 2024

Generations Family Health Center, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

To Health Resources and Services Administration Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2024 The findings from the June 30, 2024 ...

To Health Resources and Services Administration Generations Family Health Center, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2024 The findings from the June 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2024.001 - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken A discrepancy was found in the sliding fee information of a selection in the audit process. The information collected by the patient intake system was not properly entered into the practice management system for a selection. Action: A periodic sliding fee scale audit across all sites will be conducted to compare the information in the patient intake system with the data in the practice management system. If there are any question regarding this plan, please e-mail Debra Daviau Savoie at DSavoie@genhealth.org.

View Audit 329406

Finding 509716 (2024-002)

Significant Deficiency 2024

Crown College

MN

Student Financial Aid Reporting Significant Deficiency

National Student Loan Data System (NSLDS) Enrollment Reporting Award Period: July 1, 2023 to June 30, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accur...

National Student Loan Data System (NSLDS) Enrollment Reporting Award Period: July 1, 2023 to June 30, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will further collaborate and expand procedures with the Registrar office to continue to ensure that we meet the Code of Federal Regulations, 34 CFR 685.309 that requires enrollment status changes to be reported to NSLDS within 30 days or 60 days if scheduled enrollment transmission will be sent within 60 days. Specifically, adjusting procedure to ensure that all 0.0 GPA students due to F grade are reported. Name(s) of the contact person(s) responsible for corrective action: Alyssa Gillette Planned completion date for corrective action plan: November 30, 2024

View Audit 329373

Finding 509710 (2024-003)

Significant Deficiency 2024

University of Dubuque

IA

Subrecipient Monitoring Equipment & Real Property Management Matching / Level of Effort / Earmarking § 200.303

Finding: The University has not created or implemented a comprehensive information security policy. Corrective Actions Taken or Planned: These policies are currently in place and regularly practiced. Currently the University of Dubuque is in the process of formally writing up a comprehensive securi...

Finding: The University has not created or implemented a comprehensive information security policy. Corrective Actions Taken or Planned: These policies are currently in place and regularly practiced. Currently the University of Dubuque is in the process of formally writing up a comprehensive security policy. Person Responsible: Teresa Brahm, TBrahm@dbq.edu Anticipated completion date: 10/01/2024

View Audit 329370

Finding 509701 (2024-005)

Material Weakness 2024

Madison-Carver Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways:1. We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways:1. We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included.2. All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested

View Audit 329351

Finding 509691 (2024-007)

Material Weakness 2024

Cornerstone Jefferson-Douglass Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.501 § 200.512 § 200.514

Condition - The data collection form was not submitted within the required time as required by 2 CFR 200.512 for the year ended June 30, 2023. Planned Corrective Action - The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI number...

Condition - The data collection form was not submitted within the required time as required by 2 CFR 200.512 for the year ended June 30, 2023. Planned Corrective Action - The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an ongoing issue in the future. Anticipated Completion Date: November 15, 2024 Point of Contact: Mary Ann Johnson

View Audit 329348

Finding 509689 (2024-005)

Material Weakness 2024

Cornerstone Jefferson-Douglass Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Condition - During our testing for Reporting, it was noted that 2 out of 2 reports selected for testing did not have evidence of review and approval. Planned Corrective Action: Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbur...

Condition - During our testing for Reporting, it was noted that 2 out of 2 reports selected for testing did not have evidence of review and approval. Planned Corrective Action: Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: 1. We will ensure a signature and_ date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. 2. All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested. Anticipated Completion Date: December 1, 2024 Point of Contact: Mary Ann Johnson

View Audit 329348

Finding 509679 (2024-001)

Material Weakness 2024

Marshall Public Schools

MI

Questioned Costs Procurement, Suspension & Debarment Material Weakness

2024-001 – Special Tests and Provisions – Wage Rate Requirements (repeat). U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D, 84.425U and 84.425W); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect:...

2024-001 – Special Tests and Provisions – Wage Rate Requirements (repeat). U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D, 84.425U and 84.425W); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: One of the contracts selected for testing that was subject to the Wage Rate Requirements did not include the required provision, and the District did not obtain the required certified payrolls. In addition, another contract selected for testing had the Wage Rate Requirements required provision, however, the District was unable to obtain the required certified payrolls. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bidding and/or proposal process. Responsible Person: Rebecca Jones, Superintendent and Kendra Leib, Director of Finance. Anticipated Completion Date: June 30, 2025.

View Audit 329336 Questioned Costs: $1

Finding 509659 (2024-001)

Significant Deficiency 2024

Austin Public Schools

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, and 10.559 – Suspension & Debarment Recommendation: We recommend the District implement procedures and controls to ensure vendors are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagreement...

Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, and 10.559 – Suspension & Debarment Recommendation: We recommend the District implement procedures and controls to ensure vendors are not suspended or debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Food Service Director will search the Sam.Gov website before contracting with vendors for $25,000 and over, in the future to verify the entity is not suspended or debarred. Name(s) of the contact person(s) responsible for corrective action: Todd Lechtenberg, Executive Director of Finance & Operations Planned completion date for corrective action plan: June 30, 2025

View Audit 329290

Finding 509648 (2024-002)

Significant Deficiency 2024

Montgomery County Chamber of Commerce, Inc.

MD

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Views of Responsible Officials: MCCC and Affiliate have implemented a system through their payroll processor beginning the payroll cycle of 9/23/24 to 10/06/24. This includes notification to the manager’s that their staff’s timesheet has been submitted which requires their approval in iSolve. The un...

Views of Responsible Officials: MCCC and Affiliate have implemented a system through their payroll processor beginning the payroll cycle of 9/23/24 to 10/06/24. This includes notification to the manager’s that their staff’s timesheet has been submitted which requires their approval in iSolve. The unapproved payroll register issues resulted from a transition in staff. Starting November 2023, the issue has been resolved.

View Audit 329265

Finding 509642 (2024-001)

Significant Deficiency 2024

Susquehanna University

PA

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

Management agrees with the finding and the recommendations made by the auditor. Over the next thirty days Management will analyze the enrollment reporting control environment including (but not limited to) how enrollment status effective dates, for students who withdrawal after the completion of the...

Management agrees with the finding and the recommendations made by the auditor. Over the next thirty days Management will analyze the enrollment reporting control environment including (but not limited to) how enrollment status effective dates, for students who withdrawal after the completion of the semester, are identified and accounted for by Management. Within forty-five days, Management will implement enhanced enrollment reporting processes to ensure accurate and timely enrollment statuses are reported to NSLDS in compliance with federal regulations.

View Audit 329238

Finding 509610 (2024-006)

Significant Deficiency 2024

Concordia University, St. Paul

MN

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Student Financial Assistance Cluster– 84.038 – Federal Perkins Loans Recommendation: We recommend that the University implement a procedure with the third-party servicer to ensure that its Title IV compliance report is completed in a timely manner so that the University can perform the necessary due...

Student Financial Assistance Cluster– 84.038 – Federal Perkins Loans Recommendation: We recommend that the University implement a procedure with the third-party servicer to ensure that its Title IV compliance report is completed in a timely manner so that the University can perform the necessary due diligence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For 22-23, the third-party servicer provided the compliance report in March 2024. For 23-24, the third-party servicer states the report should be available by the end of December 2024. Name(s) of the contact person(s) responsible for corrective action: Michael Dorner Planned completion date for corrective action plan: Already in place

View Audit 329180

Finding 509609 (2024-005)

Significant Deficiency 2024

Concordia University, St. Paul

MN

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its current policies and procedures around credit balances and ensure the processes in place are sufficient to ensure student credit balances due to federal funds are refunded with...

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its current policies and procedures around credit balances and ensure the processes in place are sufficient to ensure student credit balances due to federal funds are refunded within 14 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An internal tracker has been created for the entire team to report why a credit balance is not released to the student; and to monitor what steps are still needed to take to clear and release the credit balance. This will allow staff and the Financial Aid Director to quickly assist when staff is unexpectedly out of the office and connect with the necessary departments. Name(s) of the contact person(s) responsible for corrective action: Amanda McCaughan Planned completion date for a corrective action plan: Put into place November 2024

View Audit 329180 Questioned Costs: $1

Finding 509603 (2024-004)

Significant Deficiency 2024

Concordia University, St. Paul

MN

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its current policies and procedures around credit balances and ensure the processes in place are sufficient to ensure student credit balances due to federal funds are refunded with...

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its current policies and procedures around credit balances and ensure the processes in place are sufficient to ensure student credit balances due to federal funds are refunded within 14 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An internal tracker has been created for the entire team to report why a credit balance is not released to the student; and to monitor what steps are still needed to take to clear and release the credit balance. This will allow staff and the Financial Aid Director to quickly assist when staff is unexpectedly out of the office and connect with the necessary departments. Name(s) of the contact person(s) responsible for corrective action: Amanda McCaughan Planned completion date for a corrective action plan: Put into place November 2024

View Audit 329180 Questioned Costs: $1

Finding 509600 (2024-003)

Significant Deficiency 2024

Concordia University, St. Paul

MN

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

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend that the University implement a review process as it relates to R2T4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding...

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend that the University implement a review process as it relates to R2T4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A report was created in response to 2022-001 that pulls all students to verify no R2T4 are missed, it was put into place and pulled at the end of the semester. This did catch the 5 students, however, instead of running at the end of the semester, it now runs every 30 days to make sure students are processed within 45 days. Name(s) of the contact person(s) responsible for corrective action: Amanda McCaughan Planned completion date for a corrective action plan: The new process started in August 2024

View Audit 329180

Finding 509588 (2024-001)

Significant Deficiency 2024

Concordia University, St. Paul

MN

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure the students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: Th...

Student Financial Assistance Cluster– Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure the students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Registrar's Office did note that while nine students were flagged within the audit review, the final report does include an additional 18 students who were not brought to the attention of the Registrar’s Office during the audit. Action taken in response to finding: The Registrar's Office worked with the National Student Clearinghouse to identify new errors with CIP code rejects. We have now updated the curriculum in our SIS to eliminate the error and review the reject report for this specific error. The Registrar's Office will modify the report schedule with the National Student Clearinghouse to every three weeks to assist NSLDS with more time to update their website to align with compliance timelines. The National Student Clearinghouse records show the submission timeline. Name(s) of the contact person(s) responsible for corrective action: Lynn Lundquist Planned completion date for a corrective action plan: The new process started in August 2024

View Audit 329180

Finding 509367 (2024-003)

None 2024

Southern Virginia University

VA

Student Financial Aid Eligibility Internal Control / Segregation of Duties

Individual Responsible for Corrective Action: Sarah Christoffersen, Director of Financial Aid Corrective Action: An incorrect satisfactory academic progress tracking status was assigned to a single student, which resulted in the one student receiving federal aid for the spring semester when they sh...

Individual Responsible for Corrective Action: Sarah Christoffersen, Director of Financial Aid Corrective Action: An incorrect satisfactory academic progress tracking status was assigned to a single student, which resulted in the one student receiving federal aid for the spring semester when they should have been marked as ineligible. The spring disbursement was corrected promptly when uncovered and funds have been returned to ED. An enhanced system is now in place to more clearly track the satisfactory academic progress of students who take a leave of absence from the university and return without demonstrating satisfactory academic progress at a different school. Anticipated Completion Date: 11/1/2024

View Audit 329155

Finding 509363 (2024-002)

Significant Deficiency 2024

Southern Virginia University

VA

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

Individual Responsible for Corrective Action: Sarah Christoffersen, Director of Financial Aid Corrective Action: This finding cumulated into three different types of issues, summarized below, and corrective action has been taken for each of the three. In addition to addressing the three issues, tra...

Individual Responsible for Corrective Action: Sarah Christoffersen, Director of Financial Aid Corrective Action: This finding cumulated into three different types of issues, summarized below, and corrective action has been taken for each of the three. In addition to addressing the three issues, training has been provided to the financial aid staff for the verification process as a whole and a report is being run several times a month to identify possible data entry errors of the verification process. 3 of the 8 students had a discrepancy in their documentation that does not result in a change to their federal aid eligibility. This has been addressed by implementing an electronic signature of the verification worksheet through DocuSign. 3 of the 8 students submitted documentation for a professional judgement that was approved, however the professional judgement flag was not properly selected. This has been addressed by reviewing the professional judgement steps taken by the financial aid team and providing training to those who submit professional judgement changes in the FAFSA Partner Portal. 2 of the 8 students had incomplete documentation saved to the student file. This has been addressed by implementing an additional step in the verification process to require a second review of verification documents by two separate staff members. Anticipated Completion Date: 11/1/2024

View Audit 329155

Corrective Action Plans

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