Corrective Action Plans

Finding 367 (2023-001)

None 2023

Jessie Trice Community Health System, Inc.

FL

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.317 § 200.318 § 200.327

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implem...

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

View Audit 770

Finding 344 (2023-002)

Significant Deficiency 2023

Southern Virginia University

VA

Student Financial Aid Special Tests & Provisions Reporting

Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: The majority of the certification delays were one day late. Corrective action has been taken. The financial aid office is working jointly with the registrar’s office to report enrollment infor...

Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: The majority of the certification delays were one day late. Corrective action has been taken. The financial aid office is working jointly with the registrar’s office to report enrollment information via the National Student Clearinghouse (NSC) which will facilitate more timely reporting of future enrollment status changes to NSLDS and reporting of all significant data elements to NSLDS. Reporting to NSC by the University Registrar’s Office has begun. Anticipated Completion Date: Completed

View Audit 719

Finding 342 (2022-002)

Significant Deficiency 2023

Arrive Ministries

MN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. ...

Finding 2022-002 - Documentation of Internal Control to Support Approvals of Payroll Charged to Federal Program. Recommendation: The Organization implemented a process to maintain documentation of the Executive Director’s approval for all pay periods. Corrective Action: We have already implemented a process for retaining the emails approving payroll period time cards by the Director and Executive Director. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 11/1/2022

View Audit 718

Finding 341 (2022-001)

Significant Deficiency 2023

Arrive Ministries

MN

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

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LT...

CORRECTIVE ACTION PLAN September 25, 2023 Arrive Ministries respectfully submits the following corrective action plan for the year ended March 31, 2023. Arrive Ministries concurs with the findings and recommendations listed below. Name and address of independent public accounting firm: BERGANKDV, LTD. 220 Park Avenue South St. Cloud, Minnesota Audit period: APRIL 1, 2022 TO MARCH 31, 2023 The findings from the September 5, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD Assistance Listing Number: 19.510 Federal Program Name: U.S. Refugee Admissions Program Name of Federal Agency: Department of State Finding 2022-001 - Time and Effort Reporting Recommendation: The Organization implement a process to track employee’s time and effort worked on federal programs. Corrective Action: We have implemented a process for employees to certify their time charged to federal programs on a monthly basis. We then adjust the financials as needed. Corrective Action owner: Jennifer Haskett, Senior Accountant Completion Date: 12/1/2022

View Audit 718

Finding 324 (2023-001)

Material Weakness 2023

Meridian Public Schools

MI

Cash Management School Nutrition Programs Special Tests & Provisions

The district has updated their spend down plan as of July 2023 to address the excess fund balance in food service. The Food Service Director and the Director of Business Services have already identified areas where there are needs for upgrades or enhancements. Over the next several months, the Exc...

The district has updated their spend down plan as of July 2023 to address the excess fund balance in food service. The Food Service Director and the Director of Business Services have already identified areas where there are needs for upgrades or enhancements. Over the next several months, the Excess Fund Balance will get used to improve the Food Service Porgram.

View Audit 627

Finding 319 (2023-001)

Significant Deficiency 2023

Community Action for Improvement, Inc.

GA

Significant Deficiency Internal Control / Segregation of Duties

CAFI's membership committee drives the recruitment process. The committee will meet again to discuss the plan to fill empty seats. The board and committee is actively recruiting to fill all seats.

View Audit 608

Finding 312 (2023-002)

Significant Deficiency 2023

Heyworth Community Unit School District No. 4

IL

Questioned Costs Equipment & Real Property Management Internal Control / Segregation of Duties

There is no disagreement with the audit finding. The District’s Grants Manager will collaborate to ensure all program equipment and property purchases exceeding $500 involving federal monies are appropriately tracked.

View Audit 587 Questioned Costs: $1

Finding 236 (2023-003)

Significant Deficiency 2023

Sunrise Community Health

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement wi...

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization's enrollment and billing department will work together to identify when any errors occur based on the documentation the patient provides. The enrollment team will verify the rate, and the billing and coding team will begin checking to ensure the rate that the patient was screened for is the rate the patient is being charged for and that the correct discoutn applies.

View Audit 487

Finding 217 (2023-002)

None 2023

Chowan University

NC

Special Tests & Provisions Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: This instance was an administrative error. Measures are in place to process refunds on a weekly basis. Anticipated Completion Date: Refund processing will be monitored on an ongoing basis.

View Audit 409

Finding 209 (2023-001)

Significant Deficiency 2023

University of Health Sciences and Pharmacy in St Louis

MO

Student Financial Aid Subrecipient Monitoring Reporting

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the N...

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the National Student Clearinghouse's (NSC's) system automatically overrides the graduation data in the University's Jenzabar report without notifying the University, a two-step corrective action plan has been initiated. The modified reporting process to improve internal controls consists of the following steps: 1. Upload the initial Jenzabar enrollment reporting into the NSC system which will show full-time enrollment for both the bachelor's degree and the PharmD program; 2. File a second report reflecting the date of completion of the bachelor's degree for all students in the integrated program to remedy the NSC system override of graduation data in the initial Jenzabar report; and 3. Conduct a manual verification of graduation data in the National Student Loan Data System to ensure complete, accurate and timely reporting of graduation information from NSC. The modified reporting process is expected to be fully implemented at the conclusion of the 2023-2024 academic year in conjunction with completion of commencement, which is scheduled to occur in May 2024.

View Audit 398

Finding 196 (2023-005)

Material Weakness 2023

Pleasant Hill Cusd 3

IL

Internal Control / Segregation of Duties

FINDINGS- MAJOR FEDERAL AWARD PROGRAMS Material Weakness U.S. DEPARTMENT OF AGRICULTURE- Child Nutrition Cluster- AL Number 10.553 and 10.553 Finding No.: 2023-005 Condition: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segreg...

FINDINGS- MAJOR FEDERAL AWARD PROGRAMS Material Weakness U.S. DEPARTMENT OF AGRICULTURE- Child Nutrition Cluster- AL Number 10.553 and 10.553 Finding No.: 2023-005 Condition: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. Recommendation: The District should segregate duties where possible. The Board should be aware of this problem and closely review and approve all financial related information. Action Taken: The District concus with the recommendation. The District has reviewed and continues to review its financial policies and procedures to better segregate duties where possible. The Superintendent continually reminds the Board of their responsibility in regards to reviewing and approving financial items and asking questions. It is not cost feasible to hire additional personnnel. Anticipated Date of Completion: Ongoing

View Audit 343

Finding 195 (2023-004)

Material Weakness 2023

Pleasant Hill Cusd 3

IL

Internal Control / Segregation of Duties

FINDINGS- MAJOR FEDERAL AWARD PROGRAMS Material Weakness U.S. DEPARTMENT OF EDUCATION- Education Stablization Fund Under the Coronavirus Aid, Relief and Economic Security Act- AL Number 84.425 Finding No.: 2023-004 Condition: The District's accounting function is controlled by a limited numbe...

FINDINGS- MAJOR FEDERAL AWARD PROGRAMS Material Weakness U.S. DEPARTMENT OF EDUCATION- Education Stablization Fund Under the Coronavirus Aid, Relief and Economic Security Act- AL Number 84.425 Finding No.: 2023-004 Condition: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. Recommendation: The District should segregate duties where possible. The Board should be aware of this problem and closely review and approve all financial related information. Action Taken: The District concus with the recommendation. The District has reviewed and continues to review its financial policies and procedures to better segregate duties where possible. The Superintendent continually reminds the Board of their responsibility in regards to reviewing and approving financial items and asking questions. It is not cost feasible to hire additional personnnel. Anticipated Date of Completion: Ongoing

View Audit 343

Finding 176 (2023-001)

Significant Deficiency 2023

Oak Haven Apartments

TX

Internal Control / Segregation of Duties HUD Housing Programs Reporting

Response: Management recorded the adjusting journal entries as proposed by the audit firm. In the future, management will ensure that depreciation and amortization of loan costs and calculated and recorded in the general ledger.

View Audit 256

Finding 165 (2023-002)

Material Weakness 2023

Low Rent Housing Agency of Grinnell, Iowa

IA

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight boar...

Finding 2023-002 Internal Control Structure Material Weakness – Eligibility, Reporting and Special Tests and provisions Repeat Finding 2022-02 I agree with finding The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board has reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 243

Finding 159 (2023-001)

Material Weakness 2023

Cornbelt Educational Cooperative

SD

Internal Control / Segregation of Duties Material Weakness Reporting

The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financia...

The Cornbelt Educational Cooperative Business Manager, Pamela Selken is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the Cooperative's business office. Staffing the office at an efficient and financially feasible level precludes the hiring of enough personnel to provide an ideal environment for the internal controls. The Administration and Advisory Board is aware of the weakness in internal controls and will continue to develop policies and procedures and provide compensating controls to reduce the risk. We will also communicate this concern with our Board of Directors. The Cornbelt Educational Cooperative did adopt an Internal Controls and Procedures policy on March 13th, 2018 that does address many of these issues, and would ask for consideration reflecting this implementation. This finding will be an ongoing process, requiring continued analysis of processes and procedures in order to minimize the risk.

View Audit 235

Finding 156 (2023-008)

Material Weakness 2023

Virginia Union University

VA

Eligibility Internal Control / Segregation of Duties

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financia...

Criteria: Recipients of HEERF funding must acknowledge that it may not condition the receipt of an emergency financial aid grant on continued or future enrollment with the Recipient. Recipients also acknowledge that it may not require a student to consent to the application of the emergency financial aid grant to the student's oustanding account balance as a condition of receipt of or eligibility for an emergency financial aid grant funding. The recipient also acknowledges that adding preconditions to receiving a financial aid grant that thwart this requirement may be subjected to oversight and corrective action. In consideration for this award, Recipients agree that they hold these grant funds in trust for students and act in the nature of a fiduciary for students. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. Now that the FY23 audit is finalized, any such compliance issues with students will be taken care of during actual registration process. In the future, any such forms that will need student authorization will be handled during the registration process. Responsbile Person(s): Robin Jefferson, Director of Student Accounts rljefferson@vuu.edu 804 342-3976. Robert Merino, Executive Director of Financial Aid jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218

Finding 149 (2023-006)

Significant Deficiency 2023

Virginia Union University

VA

Questioned Costs Internal Control / Segregation of Duties

Criteria: The Institution must verify that the student with Verification code V4 or V5 has a high school completion status and has signed an Identity of education purpose statement. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: Individual ...

Criteria: The Institution must verify that the student with Verification code V4 or V5 has a high school completion status and has signed an Identity of education purpose statement. The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: Individual files are being created and stored in a safe place during and after verification is completed. In addition, a digital copy is being placed in cloud storage. Responsible Person(s): Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218 Questioned Costs: $1

Finding 141 (2023-004)

Significant Deficiency 2023

Virginia Union University

VA

Questioned Costs Internal Control / Segregation of Duties

Criteria: The Instituion must verify that the student remains eligible to receive financial aid prior to disbursements of funds. From appendix A of compliance supplment: Student must maintain good standing, or satisfactory academic progress (34CFRs668.16, 668.32(f), 668.34, 690.75, 675.9, 676.9, 685...

Criteria: The Instituion must verify that the student remains eligible to receive financial aid prior to disbursements of funds. From appendix A of compliance supplment: Student must maintain good standing, or satisfactory academic progress (34CFRs668.16, 668.32(f), 668.34, 690.75, 675.9, 676.9, 685.200, 686.11, 20 USC 1070h; 42 CFR 57.306; 42 USC 293a(d)(2)). Satisfactory academic progress (SAP) is defined as Maintenance of satisfactory progress (2.0 GPA). The University concurs with this finding and will adhere to the corrective action plan. Corrective Action: The audit for FY22 was not finalized until June 27, 2023. The plan date for correction for this finding was December 31, 2023. Therefore, the plan was not realized due to the timing of completion of the FY22 audit. Now that the FY23 audit is completed, the Finanical Aid Team will print a report of communication sent to students who have lost their eligibility or are at risk of losing their eligibility at the end of each semester. The report will be placed in a secure location for documentation. Responsible Person(s): Robert Merino, Executive Director jrmerino@vuu.edu 281 795-6190. Planned Date of Completion of Corrective Action: December 31, 2023.

View Audit 218 Questioned Costs: $1

Finding 70 (2023-002)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to...

Criteria: According to 45 CFR 260.34, a religious organization that received Federal TANF funds shall not, in providing program services or benefits, discriminate against a TANF applicant or recipient on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in a religious practice. To ensure compliance with this requirement, Freestore Foodbank Inc. and Affiliates require all local distributors receiving commodities to sign a local distributor agreement. Condition: CSH noted two instances (in a sample of 40 local distributor agreements) where food was distributed to religious organizations that do not abide by 45 CFR 260.34. Planned Corrective Action: In one instance, management issued food to an agency which had an expired local distributor agreement. Going forward, controls will be put in place by 9/30/23 to better track agency agreements to ensure all agencies receiving food have up-to-date agreements. The second instance involved the request for TANF food to be distributed to an organization who was not participating in the program. While the organization was correctly set up in our database, food was requested to be distributed. Management will improve training for staff and run periodic reports to ensure food is going to the proper organizations. Management will also set up periodic compliance meetings with program managers to develop best practices for each of the grants by 10/31/23.

View Audit 63

Finding 69 (2023-001)

Significant Deficiency 2023

Freestore Foodbank, Inc. and Affiliates

OH

Eligibility Internal Control / Segregation of Duties

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, se...

Criteria: Under the requirements of the Office of Management and Budget, only a financially needy family that consists of, at a minimum, a minor child living with a parent or other caretaker relative, or a pregnant woman may receive TANF “assistance” or most maintenance-of-effort funded benefits, services or “assistance”. The child must be less than 18 years old, or, if a full-time student in a secondary school (or the equivalent level of vocational or technical training), less than 19 years old. Freestore Foodbank Inc. and Affiliates require all individuals receiving food to complete an eligibility form prior to receiving food. Condition: We noted one instance (in a sample of 40 clients) in which an eligibility form was not obtained prior to client receiving food. Planned Corrective Action: Management will perform periodic audits of eligibility forms starting 10/15/2023 to ensure compliance. Management will retrain staff to ensure completeness of the intake process. Furthermore, by 9/30/2023, management will work with the developers of the database to see if controls can be implemented in the software, so food cannot be distributed before the signing of the required form.

View Audit 63

Finding 1179321 (2022-011)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.309 § 200.77

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreem...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete

View Audit 391683

Finding 1175934 (2022-004)

Material Weakness 2022

Head Start of Lane County

OR

Significant Deficiency Internal Control / Segregation of Duties

Head Start of Lane County has created a timeline in partnership with Wipfli to ensure the completion of delinqunet audits and to ensure timely completion after August 31, 2026

View Audit 389901

Finding 1175570 (2022-008)

Material Weakness 2022

Dewey County

OK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.

View Audit 389361

Finding 1175569 (2022-007)

Material Weakness 2022

Dewey County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.

View Audit 389361

Finding 1174933 (2022-018)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

View Audit 388523

Corrective Action Plans

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