Corrective Action Plans

Finding 395117 (2023-001)

Significant Deficiency 2023

Hult International Business School, Inc.

MA

Internal Control / Segregation of Duties Special Tests & Provisions

To ensure compliance with federal guidelines, the School has already in September 2023 implemented a process of validating received bank information from students by issuing a $1 transaction to ensure validity. The improvement of this internal control will only be reflected in next year's audit. Fur...

To ensure compliance with federal guidelines, the School has already in September 2023 implemented a process of validating received bank information from students by issuing a $1 transaction to ensure validity. The improvement of this internal control will only be reflected in next year's audit. Further, from September 2024, the School is implementing a policy of requiring verified bank information from students expecting a loan refund in order to matriculate, which will simplify the refund process. Additionally, in those rare instances in which electronic funds transfers cannot be made, our policies and procedures will be amended so that adequate documentation of check disbursements is maintained.

View Audit 305041

Finding 395116 (2023-001)

Material Weakness 2023

Norwood Life Society

IL

Questioned Costs HUD Housing Programs Material Weakness

U.S. Department of Housing and Urban Development (“HUD”) Norwood Life Society respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discusse...

U.S. Department of Housing and Urban Development (“HUD”) Norwood Life Society respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 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—FEDERAL AWARD PROGRAMS AUDITS Department of Housing and Urban Development 2023-001 Mortgage Insurance_Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities – Assistance Listing No. 14.129 Recommendation: We recommended to Management that they continue to monitor related party transactions and request prior approval before any advances are made or considered to be made in support of other related parties in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Rick Steffens, the CFO, will oversee this plan, and the plan has been implemented and fully resolved. The unauthorized loan was due to an increasing intercompany balance due from an affiliated nursing home (“Bethesda”) who was losing money and unable to reimburse Norwood Crossing for shared bills for items including benefits and insurance. Due to the size of the losses, we realized this issue was unable to be resolved without disposing of Bethesda and began working on selling Bethesda in the second quarter of 2022. Bethesda was supposed to close on the sale on November 30, 2022, which would have solved the intercompany issue during the 2022 audit year, which was our plan. However, the sale was continuously delayed due to numerous serious issues pushing the actual sale date all the way back to July 1, 2023. The audit finding for the unauthorized intercompany loan was for $1,724,731.69, and was a finding on the 2022 audit. However, the intercompany balance continued to grow in 2023 and had an additional $574,583.86 of expenses that built up in 2023 before the sale occurred. This made a grand total of $2,299,315.55 that needed to be repaid from Bethesda to Norwood Crossing for the unauthorized intercompany loans through the sale date. Bethesda worked to repay the intercompany loans the best it could during 2023 before the sale occurred, and completely paid down the remaining balance on the unauthorized intercompany loans shortly after the sale of Bethesda occurred. The following payments were made from Bethesda to Norwood Crossing: Payment Dates Payment Amounts 5/8/2023 $675,000.00 5/23/2023 $350,000.00 7/17/2023 $1,274,315.55 Total $2,299,315.55 These repayments above fully resolved the unauthorized intercompany loans that were 1) in the 2022 Audit as a finding, 2) increases that occurred in 2023 after the 2022 year end, and 3) the resolutions occurred before the 2022 audit was issued and only are a finding in the 2023 audit because the loans were not fully paid off as of 2022. Furthermore, Bethesda has officially been sold as of July 1, 2023 and is no longer causing this issue to continue to occur going forward. Name(s) of the contact person(s) responsible for corrective action: Rick Steffens Planned completion date for corrective action plan: July 17, 2023 If the Oversight Agency for Audit has questions regarding this plan, please call Rick Steffens at 773-577-5334.

View Audit 305038 Questioned Costs: $1

Finding 395113 (2023-003)

Significant Deficiency 2023

East Liberty Family Health Care Center INC

PA

Eligibility Internal Control / Segregation of Duties

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from ...

Since taking over the financial management of ELFHCC in December 2022, the sliding fee schedule policy has been updated and training has been implemented and ongoing to assure accurate sliding fee discounts are appropriately distributed onto a patient’s account. Check lists of what is required from each patient applying for a sliding fee discount have been prepared and staff trained on how to enter the proof requirement into ELFHCC’s patient record

View Audit 305032

Finding 395111 (2023-001)

Material Weakness 2023

East Liberty Family Health Care Center INC

PA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular and continual basis. Policies and procedures have been created, changed, updated and Board approved. All financial r...

Since taking over the financial management of ELFHCC in December 2022 we have reorganized the financial reporting process and have been able to ensure meaningful analysis on a regular and continual basis. Policies and procedures have been created, changed, updated and Board approved. All financial reporting is prepared, analyzed and presented each month without delay.

View Audit 305032

Finding 395092 (2023-005)

Significant Deficiency 2023

City of South Portland, Maine

ME

Reporting Internal Control / Segregation of Duties

Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective dat...

Management’s Response/Corrective Action Plan: Discrepancies noted above are due to the timing of transactions posting in the accounting system where period transactions are not posted until after the data is gathered for the report or even after the reporting period, but still has an effective date within the period, so it is not picked up when reports are filed. They are corrected in the following quarterly report. For TRUCK/LFVNT, the amounts were correct but just not in the period reported, and were corrected in subsequent reports. We can try to have another person duplicate the calculation of amounts for the reporting, which will depend on staffing level and time of year. The reporting site is also difficult and in order to be able to file on time, we really need to start mid-month to make sure it’s working and allow time for contacting the helpdesk to resolve any technical issues.

View Audit 305015

Finding 395088 (2023-003)

Material Weakness 2023

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...

Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.

View Audit 305015

Finding 395087 (2023-004)

Material Weakness 2023

City of South Portland, Maine

ME

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School D...

Management’s Response/Corrective Action Plan: The School Department has had turnover in positions that have had oversight and direct involvement in this process. In some cases, the established process was followed as constructed; however, in others, gaps in coverage are clearly exposed. The School Department agrees that the management of important documents has been inconsistent. In the future, the School Department will be assigning the management of these documents to positions where turnover is less likely to occur and a more consistent process is maintained.

View Audit 305015

Finding 395041 (2023-002)

Material Weakness 2023

The Institute of World Politics

DC

Student Financial Aid Allowable Costs / Cost Principles Material Weakness

Identifying Number: Finding No. 2023-002: Special Tests – Enrollment Reporting and Gramm-Leach-Bliley Act Compliance/Material Weakness Finding: Instances of noncompliance have been identified around major compliance requirements Enrollment Reporting and Gramm-Bleach-Bliley Act, which are both part...

Identifying Number: Finding No. 2023-002: Special Tests – Enrollment Reporting and Gramm-Leach-Bliley Act Compliance/Material Weakness Finding: Instances of noncompliance have been identified around major compliance requirements Enrollment Reporting and Gramm-Bleach-Bliley Act, which are both part of special tests identified in the 2023 Compliance Supplement. ¬ Corrective Actions Taken or Planned: Responsible Official: Iman Riddick, Registrar, Dean Lane, Chief Information Officer (CIO) Anticipated Completion Date: 06/30/2024 View of Responsible Individuals: Management agrees with the assessment and finding. Dean Lane, CIO, will review the annual updates to the Student Financial Assistance Cluster within the OMB Compliance Supplement to ensure the Institute has policies, procedures, and controls in place for all required compliance requirements. For the noncompliance identified around the Gramm-Leach Bliley Act, the Institute will ensure compliance by establishing a formal written policy that will be created by Dean Lane, CIO, that addresses all required elements for a written information security program listed in the OMB Compliance Supplement. The CFO will review the policy once completed to ensure all required elements within the Compliance Supplement are included. For the noncompliance identified around the Enrollment Reporting special test, the Institute plans to have the Registrar attend comprehensive trainings around enrollment reporting offered by the National Student Clearinghouse (NSC) to further educate and enhance their understanding around the enrollment reporting compliance requirement. In addition, the Institute will have each month’s enrollment data submission by the Registrar to the National Student Clearinghouse reviewed by the Director of Financial Aid to verify completeness, accuracy, and timeliness of reporting. This will allow the Institute to correct any inaccurate reporting and verify timely submissions.

View Audit 304975

Finding 395031 (2023-005)

Material Weakness 2023

Florida Rural Legal Services, Inc.

AL

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.303

This finding is related to activities on our VOCA grants. As was the case in Finding #004, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via te...

This finding is related to activities on our VOCA grants. As was the case in Finding #004, the majority of the exceptions were related to either finding #2 above or were related to the process in place prior to May 2023. Again, in May 2023 FRLS added an electronic transaction approval process via teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. It was also noted that our process of allocating costs from our overhead cost centers to our various grants, was not fully documented. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This review will be completed within the next 90 days.

View Audit 304969

Finding 395029 (2023-001)

Material Weakness 2023

Child Care Links Association

KS

Internal Control / Segregation of Duties

Procedures should be established and implemented where the Organization segregates duties in the receipts and expenditures cycles and implements additional controls over the accounting and recording functions. Involvement by the Board of Directors can help mitigate the risk of error or fraud. The Bo...

Procedures should be established and implemented where the Organization segregates duties in the receipts and expenditures cycles and implements additional controls over the accounting and recording functions. Involvement by the Board of Directors can help mitigate the risk of error or fraud. The Board of Directors should remain involved in the financial affairs of the Organization with oversight and independent review of internal control functions.

View Audit 304965

Finding 395027 (2023-102)

Significant Deficiency 2023

Community Legal Services

AZ

Special Tests & Provisions Reporting Significant Deficiency

Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and place...

Prior to 2018, obtaining the simple agreement, when required by LSC regulations, was the responsibility of the managing attorney for the unit or office. In 2018, this responsibility was transferred to the Human Resources Administrator to ensure this document and others were timely obtained and placed in the employee’s personal file. Based on these findings, all current employees, for whom a simple agreement was not in the personnel file, were required to sign the agreement or submit a copy of the agreement they previously signed. All current employees, required to sign the simple agreement, have one on file. Human Resources will continue to obtain the agreements as part of the new employee onboarding process.

View Audit 304957

Finding 395025 (2023-101)

Significant Deficiency 2023

Community Legal Services

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties

One of the two meeting minutes noted, January 30, 2023, was approved at the March 3, 2023 board meeting and submitted to LSC on May 9, 2023. The minutes of the May 22, 2023 meeting have not been approved and should not have been submitted on September 7, 2023. The minutes for the May 22, 2023 meetin...

One of the two meeting minutes noted, January 30, 2023, was approved at the March 3, 2023 board meeting and submitted to LSC on May 9, 2023. The minutes of the May 22, 2023 meeting have not been approved and should not have been submitted on September 7, 2023. The minutes for the May 22, 2023 meeting will be placed on the upcoming Executive Committee meeting agenda for review and approval as appropriate. Upon approval, the May 22, 2023 meeting minutes will be re‐submitted to LSC. CLS recently implemented a new process. If there is not a quorum at a full board meeting, the minutes that were on that meeting’s agenda for approval will be placed on the next scheduled Executive Committee meeting for review and approval. For example, if there is no quorum at the January full board meeting, all meeting minutes that were scheduled for review and approval at that meeting will be placed on the agenda for the Executive Committee meeting later that month for approval and reported out to the full board at its next regularly scheduled meeting in March. This will ensure timely review, approval and submission of minutes for board and committee meetings.

View Audit 304957

Finding 395008 (2023-006)

Significant Deficiency 2023

National Organization for Victim Assistance, Inc.

VA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2023-006 Timely Submission of Quarterly Financial Status Reports The Director of Finance will ensure Financial Status Reports are filed timely. The deadlines will be added to a calendar that tracks deadlines, maintained by the Director of Finance.

View Audit 304930

Finding 395003 (2023-004)

None 2023

Legal Aid Society of Mid-New York, Inc.

NY

Reporting Internal Control / Segregation of Duties

The Executive Director is currently working with senior management to review and update the Organization's accounting procedures manual to align it to the LSC Financial Guide.

View Audit 304918

Finding 395000 (2023-003)

Significant Deficiency 2023

Elk County Housing Authority

PA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding 2023-003 Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure that the appropriate procedures are followed when housing quality inspection deficiencies are not resolved in the ...

Finding 2023-003 Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure that the appropriate procedures are followed when housing quality inspection deficiencies are not resolved in the required timeframe, as required by HUD (24 CFR 882.516) and the Uniform Guidance. Action taken: Using the newly implemented process for setting and updating google calendars with reminders.

View Audit 304912 Questioned Costs: $1

Finding 394999 (2023-002)

Significant Deficiency 2023

Elk County Housing Authority

PA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding 2023-002 Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure that all housing quality inspections are being performed throughout the year, as required by HUD and the Uniform G...

Finding 2023-002 Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure that all housing quality inspections are being performed throughout the year, as required by HUD and the Uniform Guidance. Action taken: The Section 8 Coordinator will print an updated calendar of the upcoming inspection schedule for comparison to the Inspector's calendar and continue to update the google calendar and set daily reminders.

View Audit 304912 Questioned Costs: $1

Finding 394998 (2023-001)

Significant Deficiency 2023

Elk County Housing Authority

PA

Questioned Costs HUD Housing Programs Eligibility

Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure all required Income verification and other supporting documentation is obtained when completing the HUD-50058 forms, and to the exte...

Department of Housing and Urban Development Housing Voucher Cluster - ALN Number 14.871 Recommendation: We recommend that the Authority implement procedures to ensure all required Income verification and other supporting documentation is obtained when completing the HUD-50058 forms, and to the extent they are not, that action be taken to resolve any issues, and that this action be documented Action taken: Updated "How To" and the file guides. The entire file will be reviewed at all Interims and Re certifications. The Operations Manager/Compliance Officer will review each file for quality control. I have attended training provided by Nelrod and will continue to do so.

View Audit 304912 Questioned Costs: $1

Finding 394977 (2023-001)

Material Weakness 2023

Nelsonville-York City School District

OH

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

The Treasurer will review both the elementary and the jr high/high school lunch and breakfast counts prior to the claims being submitted to CRRS.

View Audit 304873

Finding 394956 (2023-003)

Material Weakness 2023

Central Vermont Supervisory Union #68

VT

Internal Control / Segregation of Duties

The Director of Finance and Operations will work with staff immediately to ensure that the recommendation from the auditor is implemented immediately. Effective April 1, 2024 – this is in place and happening. Chris Locarno, Director of Finance and Operations, is responsible for implementing this co...

The Director of Finance and Operations will work with staff immediately to ensure that the recommendation from the auditor is implemented immediately. Effective April 1, 2024 – this is in place and happening. Chris Locarno, Director of Finance and Operations, is responsible for implementing this corrective action plan. We plan to rectify all actions by June 30, 2024.

View Audit 304816

Finding 394953 (2023-005)

Material Weakness 2023

Southwestern Adventist University

TX

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Material Weakness

Corrective Action: The University has contracted with Grant Works to review current internal controls and develop a comprehensive plan to strengthen compliance and identify gaps in current policies and procedures. The firm will conduct an extensive review of awarded grants and regulations as outline...

Corrective Action: The University has contracted with Grant Works to review current internal controls and develop a comprehensive plan to strengthen compliance and identify gaps in current policies and procedures. The firm will conduct an extensive review of awarded grants and regulations as outlined in 2 CFR 200, providing recommendations and a week-long training for all grant staff, financial management staff, and identified administrators. Contact Person: Austen Powell, Director of Sponsored Projects Administration Completion Date: In progress, contract signed, and services started 3/19/24

View Audit 304813

Finding 394945 (2023-002)

Significant Deficiency 2023

Legal Aid Chicago

IL

Allowable Costs / Cost Principles Reporting Significant Deficiency

Recommendation: We recommend that management review its policies and procedures surrounding cut-off around the end of reporting periods to ensure disbursements are recorded in the correct reporting period. Views of Responsible Official: There is no disagreement with this finding. Action taken in r...

Recommendation: We recommend that management review its policies and procedures surrounding cut-off around the end of reporting periods to ensure disbursements are recorded in the correct reporting period. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: The Organization will continue to enhance our grant-end and year-end transaction monitoring to ensure appropriate treatment of expenses. Additionally, the organization will enhance communication with staff across the Organization to share grant and fiscal-year related deadlines

View Audit 304811

Finding 394944 (2023-001)

Significant Deficiency 2023

Legal Aid Chicago

IL

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run ...

Recommendation: We recommend that management implement a control to review PAI time entries to ensure they are accurate. Views of Responsible Official: There is no disagreement with this finding. Action taken in response to finding: On a monthly basis, the Deputy Director/General Counsel will run a LegalServer report on PAI time, including missing activity details, and will follow up with each person to correct their time records as needed. We will also provide additional training to staff on requirements for classifying time as PAI, and the importance of accuracy in timekeeping detail.

View Audit 304811

Finding 394876 (2023-005)

Material Weakness 2023

Middle MacOupin Health Care Systems and Affiliates

IL

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #370645239 Reporting Finding Summary: The Organization included a lost revenues...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #370645239 Reporting Finding Summary: The Organization included a lost revenues in the Department of Health and Human Services (HHS) special report for Period 4 that were incorrectly calculated which caused the report to be inaccurate. Responible Individuals: Paul Courtney, CFO Corrective Action Plan: Management will enhance internal controls to ensure the lost revenue calculation reported on the HHS special report meet the requirements of the federal program. Anticipated Completion Date: June 30, 2024

View Audit 304765

Finding 394875 (2023-004)

Material Weakness 2023

Middle MacOupin Health Care Systems and Affiliates

IL

HUD Housing Programs Material Weakness Reporting

Department of Housing and Urban Development Federal Financial Assistance Listing #14.128 Section 242 – Mortgage Insurance ‐ Hospitals Reporting Finding Summary: The Section 242 – Mortgage Insurance ‐ Hospitals Program requires quarterly reports and certain annual reports. For the year ended July 31,...

Department of Housing and Urban Development Federal Financial Assistance Listing #14.128 Section 242 – Mortgage Insurance ‐ Hospitals Reporting Finding Summary: The Section 242 – Mortgage Insurance ‐ Hospitals Program requires quarterly reports and certain annual reports. For the year ended July 31, 2023, the Organization failed to file the annual budget prior to the start of the year. Responsible Individuals: Paul Courtney, CFO Corrective Action Plan: Management will enhance internal controls to ensure that required reports under the Section 242 Program are submitted timely and accurately. Anticipated Completion Date: June 30, 2024

View Audit 304765

Finding 394865 (2023-007)

Significant Deficiency 2023

Rocky Boy Public Schools

MT

Procurement, Suspension & Debarment Subrecipient Monitoring Equipment & Real Property Management

FINDING 2023-007: Misclassification of Capital Purchases Response: District Clerk and Business Manager will ensure all capital purchases are correctly classified and coded within the 730 [major equipment-new] or 740 [major equipment- replacement] object line items. It will also be the Clerk's re...

FINDING 2023-007: Misclassification of Capital Purchases Response: District Clerk and Business Manager will ensure all capital purchases are correctly classified and coded within the 730 [major equipment-new] or 740 [major equipment- replacement] object line items. It will also be the Clerk's responsibility to ensure capital purchase expenditure lines arc built within annual budgets.

View Audit 304754

Corrective Action Plans

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