Corrective Action Plans

Finding 7606 (2023-002)

Significant Deficiency 2023

MT

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development CFDA #: 14-871 Housing Choice Voucher Program Applicable Federal Award Number and Year – 2023 Special Tests and Provisions Significant Deficiency in Internal Control over Compliance Finding Summary: HQS Enforcement there was 1 instance in which the la...

U.S. Department of Housing and Urban Development CFDA #: 14-871 Housing Choice Voucher Program Applicable Federal Award Number and Year – 2023 Special Tests and Provisions Significant Deficiency in Internal Control over Compliance Finding Summary: HQS Enforcement there was 1 instance in which the landlord didn’t correct the cited HQS deficiencies within the specified correction period and Housing Authority of Billings failed to abate the HAP timely. Responsible Individuals: Patti Webster, Chief Executive Officer / Executive Director and Helen Verhasselt, CFO Corrective Action Plan: Management agrees with the finding. The organization has completed retraining of staff and stressed the importance of following the Administrative Plan. The HCV Director is reviewing all HQS inspections monthly and conducts cross reference checks to ensure timely actions are taken on failed inspections. Anticipated Completion Date: December 20, 2023

View Audit 9948

Finding 7598 (2023-001)

Significant Deficiency 2023

Ozarks Resource Group D/b/a Ozarks Community Health Center

MO

Subrecipient Monitoring Eligibility HUD Housing Programs

Corrective Action Plan Year Ended May 31, 2023 To United States Department of Health and Human Services Ozarks Community Health Center respectfully submits the following corrective action plan for the year ended May 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: ...

Corrective Action Plan Year Ended May 31, 2023 To United States Department of Health and Human Services Ozarks Community Health Center respectfully submits the following corrective action plan for the year ended May 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: May 31, 2023 The findings from the May 31, 2023 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 2023.001 - Sliding Fee Scale Documentation Recommendation The Organization should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discounts. Action Taken Beginning June 1, 2023, management has… If there are any question regarding this plan, please e-mail Lindsay Pearson at lindsay.pearson@ozarkschc.com. Sincerely, Lindsay Pearson Chief Financial Officer

View Audit 9941

Finding 7596 (2023-002)

Material Weakness 2023

Riverside Community School District

IA

Internal Control / Segregation of Duties

Will continue to review our procedures and implement controls when possible

View Audit 9939

Finding 7582 (2023-002)

Material Weakness 2023

Franciscan Missionaries of Our Lady Health System, Inc.

LA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Corrective Action Plan The reconciliation review process will be enhanced for funding that applies to multiple funding periods. Anticipated Completion Date To be corrected with the Period 6 PRF portal submission Name of Contact Person for Corrective Action Rebecca Villar, Director of Accounting

View Audit 9933

Finding 7577 (2023-004)

Material Weakness 2023

Bethany Lutheran Home for the Aged, Inc.

SD

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookk...

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookkeeping and bank account. However, management transposed the $116,400 amount that was required to be in the reserve account according to the Letter of Conditions. The Organization underfunded the actual reserve balance after interest earnings by $521 as of June 30, 2023. Additionally, the Organization withdrew $100,000 in May 2023 from the reserve account to deposit into the operating account and subsequently replenished the reserve account within 14 days without obtaining proper federal agency approval. Responsible Individuals: Dalton Huber, Chief Financial Officer Corrective Action Plan: A new line of credit has been established at First Interstate Bank to prevent this from reoccurring. The correct amount is presently in the reserve account. Anticipated Completion Date: 10/1/2023

View Audit 9917

Finding 7541 (2023-007)

Material Weakness 2023

Independent School District No. 2342 Wca Public Schools

MN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness

Lack of Proper Review – Allowable Costs Federal agency: U.S. Department of Agriculture Federal program Title: Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Identification Number and Year: 212MN061N1199- 2023 Pass-Through Agency: Minnesota Department of Education Pas...

Lack of Proper Review – Allowable Costs Federal agency: U.S. Department of Agriculture Federal program Title: Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Identification Number and Year: 212MN061N1199- 2023 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): Not applicable Award Period: June 30, 2023 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the District have someone review all journal entries. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The District will implement procedures to ensure all journal entries are properly reviewed. Name of the Contact Person Responsible for Corrective Action Plan: Paul Brownlow, Superintendent Planned Completion Date for Corrective Action Plan: June 30, 2024.

View Audit 9837

Finding 7536 (2023-006)

Material Weakness 2023

Independent School District No. 2342 Wca Public Schools

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

Lack of Proper Review Federal agency: U.S. Department of Agriculture Federal program Title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556 Federal Award Identification Number and Year: 212MN061N1199- 2023 Pass-Through Agency: Minnesota Department of Education Pass-Throug...

Lack of Proper Review Federal agency: U.S. Department of Agriculture Federal program Title: Child Nutrition Cluster Assistance Listing Number: 10.553, 10.555, 10.556 Federal Award Identification Number and Year: 212MN061N1199- 2023 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-2342-000 Award Period: June 30, 2023 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the District review paper applications. The District should ensure that these controls are properly documented. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The District will implement procedures to ensure all paper transactions are properly reviewed once completed. Name of the Contact Person Responsible for Corrective Action Plan: Paul Brownlow, Superintendent Planned Completion Date for Corrective Action Plan: June 30, 2024.

View Audit 9837

Finding 7535 (2023-003)

Significant Deficiency 2023

Tri County Area Schools

MI

Reporting Internal Control / Segregation of Duties

Management and the Board will continue to designate competent staff to oversee and review the financial reports and approve them before issuance. However, it is not feasible or cost effective to odd staff with the competence to prepare these reports.

View Audit 9835

Finding 7534 (2023-002)

Significant Deficiency 2023

Tri County Area Schools

MI

Internal Control / Segregation of Duties

Management and the Board will continue to be aware of this condition and continue to be involved in the matters relating to the Organization's operations. However, it is not feasible or cost effective to add staff to achieve the desired level of internal control.

View Audit 9835

Finding 7516 (2023-003)

Material Weakness 2023

Platte Health Center

SD

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

Single Audit Finding 2023-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Health Center does not have controls in place to ensure compliance with the requirements as th...

Single Audit Finding 2023-003 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Health Center does not have controls in place to ensure compliance with the requirements as they have not been calculating or monitoring the required debt ratios. The Health Center was relying on annual calculations performed by the Eide Bailly audit team. Responsible Individuals: Vicki Jensen, Chief Financial Officer Corrective Action Plan: Platte Health Center will perform debt service ratio and working capital calculations and implement a review process over the calculations as part of their year-end close process to ensure all covenants of the loan are met. Anticipated Completion Date: June 30, 2024

View Audit 9749

Finding 7515 (2023-001)

Material Weakness 2023

Realife Cooperative of Hibbing South

MN

Reporting Internal Control / Segregation of Duties

The finding from the October 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed...

The finding from the October 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 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.

View Audit 9742

Finding 7514 (2023-006)

Significant Deficiency 2023

School District of Cadott Community

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Sue Shakal Anticipated Completion Date: Ongoing

View Audit 9733

Finding 7509 (2023-005)

Significant Deficiency 2023

School District of Cadott Community

WI

Internal Control / Segregation of Duties Reporting Significant Deficiency

Due to its size, it is not cost effective to hire additional staff to complete necessary reporting. Reviews and checks will be put into place prior to claim submissions with existing staff members. Responsible Person: Sue Shakal Anticipated Completion Date: Ongoing

View Audit 9733

Finding 7499 (2023-003)

Significant Deficiency 2023

School District of Cadott Community

WI

School Nutrition Programs Allowable Costs / Cost Principles Eligibility

The District will assign someone in the Business Office to review the Child Nutrition claims. Due to the size of the District, it is not cost effective to have more than one person in the food service department working with the claims. A school business official will review all claims. Responsi...

The District will assign someone in the Business Office to review the Child Nutrition claims. Due to the size of the District, it is not cost effective to have more than one person in the food service department working with the claims. A school business official will review all claims. Responsible Person: Sue Shakal Anticipated Completion Date: Ongoing

View Audit 9733

Finding 7471 (2023-006)

Significant Deficiency 2023

Harris-Stowe State University

MO

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding 2023-006 Personnel Responsible for Corrective Action: Registrar – Yolanda Kenton Anticipated Completion Date: December 2023 Corrective Action Plan: The University filled the Registrar position which had been vacant for 6 months. In addition, the Registrar’s Office implemented a control...

Finding 2023-006 Personnel Responsible for Corrective Action: Registrar – Yolanda Kenton Anticipated Completion Date: December 2023 Corrective Action Plan: The University filled the Registrar position which had been vacant for 6 months. In addition, the Registrar’s Office implemented a control that includes running a monthly enrollment status report allowing for changes to be reported within the 60 day window. The current Registrar has also done Registrar training with the American Association of Collegiate Registrars and Admissions Officers (AACRAO).

View Audit 9669

Finding 7464 (2023-001)

Significant Deficiency 2023

Colony Square Cooperative

MN

Reporting Internal Control / Segregation of Duties

Housing and Urban Development Colony Square Cooperative respectfully submits the following corrective action plan for the year ended October 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: October 31, 2023 The finding from the October 31, 2023 sch...

Housing and Urban Development Colony Square Cooperative respectfully submits the following corrective action plan for the year ended October 31, 2023. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: October 31, 2023 The finding from the October 31, 2023 schedule of findings and questioned costs and the summary schedule of prior audit findings is discussed below. The finding is numbered consistently with the number assigned in the schedules. Summary of audit results does not include findings and is not addressed. Finding 2023-001 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.

View Audit 9639

Finding 7460 (2023-004)

Material Weakness 2023

Independent School District No. 593

MN

Special Tests & Provisions Internal Control / Segregation of Duties

Contact Person - Randal Bergquist, Superintendent; Corrective Action Plan - The District will review its policies and procedures for vendor contracts and certified payrolls. Completion Date - January 31, 2024.

View Audit 9627

Finding 7454 (2023-001)

Material Weakness 2023

Hawthorn Academy

UT

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Finding Summary: Hawthorn Academy is required to adhere to Davis-Bacon prevailing wage requirements on all program expenditures relating to minor remodeling, renovation or construction contracts over $2,000 and use laborers or mechanics. Hawthorn Academy failed to inform their contractor of this req...

Finding Summary: Hawthorn Academy is required to adhere to Davis-Bacon prevailing wage requirements on all program expenditures relating to minor remodeling, renovation or construction contracts over $2,000 and use laborers or mechanics. Hawthorn Academy failed to inform their contractor of this requirement and as a result no documentation was retained by either Hawthorn Academy or the contractor on the wages paid to laborers who worked on the carpet removal and installation project. Responsible Individuals: Accountant and Lead Director Corrective Action Plan: Management will keep better track of which program expenditures are relating to such contracts noted above and inform contractors of the Davis-Bacon prevailing wage requirements and require them to provide sufficient documentation to test the wages paid to their laborers and ensure they are adhering to Davis-Bacon prevailing wage requirements. Anticipated Completion Date: Ongoing Anticipated Completion Date: Management will ensure all necessary corrective action plan items are in place by the end of the next fiscal period.

View Audit 9621

Finding 7429 (2023-002)

Significant Deficiency 2023

Randolph School District

WI

Internal Control / Segregation of Duties

Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Board will continue to be aware of this condition and continue to be involved in the matters relating to the District’s operations. However, it is not feasible or cost effect...

Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Board will continue to be aware of this condition and continue to be involved in the matters relating to the District’s operations. However, it is not feasible or cost effective to add staff to achieve the desired level of internal control.

View Audit 9585

Finding 7403 (2023-001)

Significant Deficiency 2023

Louisiana Key Academy

LA

School Nutrition Programs Special Tests & Provisions Internal Control / Segregation of Duties

Finding 2023-01 Internal Control Over Compliance of Special Tests and Provisions – Non-Profit School Food Service Accounts View of Responsible Official: The School agrees to solely use the food service bank account for all revenues and expenses related to the food service program. The School will b...

Finding 2023-01 Internal Control Over Compliance of Special Tests and Provisions – Non-Profit School Food Service Accounts View of Responsible Official: The School agrees to solely use the food service bank account for all revenues and expenses related to the food service program. The School will begin the process of transitioning bank information to respective vendors and governmental agencies to ensure the monies received for the food service program are deposited into the account and expenses for the food service program are paid out of this account. Contact Person: Tory Jones, Finance Director Expected Implementation Date: February 2024

View Audit 9554

Finding 7395 (2023-006)

None 2023

Lafayette Prish School Board

LA

Cash Management Internal Control / Segregation of Duties

Recommendation: There were inadequate controls over documentation of the number of students receiving snacks that are claimed for reimbursement. Supporting documentation relating to snacks is not being properly maintained. The School Board should implement policies and procedures to ensure that supp...

Recommendation: There were inadequate controls over documentation of the number of students receiving snacks that are claimed for reimbursement. Supporting documentation relating to snacks is not being properly maintained. The School Board should implement policies and procedures to ensure that supporting documentation is maintained for all snacks served. Corrective Action Plan: While testing one school’s snack counts for one month, two of the days’ snack counts were not properly documented. This particular instance has been addressed with the related staff. Proper documentation will be maintained by all schools that serve Snacks under the respective program. Student counts will be recorded to substantiate subsequent reimbursements. On a monthly basis, these records will be monitored by an Area Supervisor. Prior to a reimbursement claim being submitted, the daily record will be reviewed and total meals will be verified for accuracy.

View Audit 9532

Finding 7394 (2023-003)

Material Weakness 2023

Lafayette Prish School Board

LA

Cash Management Internal Control / Segregation of Duties

Recommendation: There were inadequate controls over documentation of the number of students receiving snacks that are claimed for reimbursement. Supporting documentation relating to snacks is not being properly maintained. The School Board should implement policies and procedures to ensure that supp...

Recommendation: There were inadequate controls over documentation of the number of students receiving snacks that are claimed for reimbursement. Supporting documentation relating to snacks is not being properly maintained. The School Board should implement policies and procedures to ensure that supporting documentation is maintained for all snacks served. Corrective Action Plan: While testing one school’s snack counts for one month, two of the days’ snack counts were not properly documented. This particular instance has been addressed with the related staff. Proper documentation will be maintained by all schools that serve Snacks under the respective program. Student counts will be recorded to substantiate subsequent reimbursements. On a monthly basis, these records will be monitored by an Area Supervisor. Prior to a reimbursement claim being submitted, the daily record will be reviewed and total meals will be verified for accuracy.

View Audit 9532

Finding 7314 (2023-001)

Material Weakness 2023

Rowan County, North Carolina

NC

Eligibility Material Weakness Internal Control / Segregation of Duties

Corrective Action/Management Response: The Department concurs that casefile did not include documentation of a signed application form, either paper or telephonic. 1. All staff responsible for working LIEAP applications will receive refresher training that covers all program requirements with an e...

Corrective Action/Management Response: The Department concurs that casefile did not include documentation of a signed application form, either paper or telephonic. 1. All staff responsible for working LIEAP applications will receive refresher training that covers all program requirements with an emphasis on basic documentation requirements. 2. Quality Assurance Lead Workers/Trainers will conduct targeted 2nd party reviews during the coming year to identify and address any ongoing challenges with this item.

View Audit 9488

Finding 7313 (2023-002)

Significant Deficiency 2023

Rowan County, North Carolina

NC

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Corrective Action/Management Response: The Department concurs that an employee left the office unattended while logged into a state platform. 1. Management will partner with the Rowan County Information Technology Department to ensure the highest level of automatic screen locking is set as a defau...

Corrective Action/Management Response: The Department concurs that an employee left the office unattended while logged into a state platform. 1. Management will partner with the Rowan County Information Technology Department to ensure the highest level of automatic screen locking is set as a default for devices. 2. All staff will receive refresher training on the duty to protect confidential information and prevent the potential for unauthorized access to sensitive information and systems. 3. Management will arrange for random spot checks of offices at least monthly for 3 months, then sporadically thereafter. Management will address any exceptions to screen lock/logout in unattended offices through individual coaching and supervision.

View Audit 9488

Finding 7312 (2023-003)

Significant Deficiency 2023

Rowan County, North Carolina

NC

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Corrective Action/Management Response: The accounting for employee hours requires the review of timesheets to verify employees are recording scheduled hours appropriately. In conjunction with this review, changes may be required to timesheets. To verify that changes need to be made and then have be...

Corrective Action/Management Response: The accounting for employee hours requires the review of timesheets to verify employees are recording scheduled hours appropriately. In conjunction with this review, changes may be required to timesheets. To verify that changes need to be made and then have been made correctly, the review of a “Time Entry Hours Report” has been incorporated into our payroll processing. This report records the number of hours an employee is being paid. This report is reviewed numerous times within the payroll process, prior to the “true up” changes and after changes for verification of accuracy. Proposed Completion Date: May 2023

View Audit 9488

Corrective Action Plans

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