Corrective Action Plans

Finding 380754 (2023-001)

Material Weakness 2023

AR

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

Corrective Action: The district will contact the Federal Communications Commission for guidance on the matter. If necessary, the computers in question will be distributed in the appropriate manner in accordance with the regulation.

View Audit 295432 Questioned Costs: $1

Finding 380754 (2023-001)

Material Weakness 2023

Huntsville School District

AR

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

Anticipated Completion Date: June 30, 2024

View Audit 295432 Questioned Costs: $1

Finding 380753 (2023-001)

Material Weakness 2023

Millcreek Community Hospital

PA

Questioned Costs Material Weakness Reporting § 200.303

Condition During the performance of our procedures, we noted that the Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that Hospital had errors in the underlying support to the lost revenue calculation, resulting in lo...

Condition During the performance of our procedures, we noted that the Hospital did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that Hospital had errors in the underlying support to the lost revenue calculation, resulting in lost revenues being overstated $246,892. The entity reported lost revenues amounting to $3,973,310 on distributions totaling $2,485,265. The Hospital also had excess lost revenues from prior periods available to be used through June 30, 2023 amounting to $11,388,637. Corrective Action Plan Corrective Action Planned: The Organization will undertake a review of its internal control policies and procedures surrounding the reporting on federal grant activities and add additional layers of review where necessary to ensure future reporting is accurate. Name(s) of Contact Person(s) Responsible for Corrective Action: Richard Lusk, CFO Anticipated Completion Date: The anticipated completion date is June 30, 2024

View Audit 295425

Finding 380722 (2023-002)

Significant Deficiency 2023

Soledad Unified School District

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

The Business Office, in coordination with the Human Resources Department, is developing a process to ensure timely reviews and approvals of employee time and effort charged to federal programs is documented on a periodic basis. The corrective action is expected to be implemented by June 30, 2024.

View Audit 295400

Finding 380702 (2023-008)

Significant Deficiency 2023

New American Association of Massachusetts, Inc.

MA

Cash Management Internal Control / Segregation of Duties Questioned Costs § 200.302 § 200.303

The newly hired CFO will update the policies and procedures and oversee the Finance Department and will develop procedures to ensure there are proper segregation of duties over key cycles, taking into consideration the size and complexity of the Organization. These procedures will strengthen the exp...

The newly hired CFO will update the policies and procedures and oversee the Finance Department and will develop procedures to ensure there are proper segregation of duties over key cycles, taking into consideration the size and complexity of the Organization. These procedures will strengthen the expense and accounts payable processes to ensure compliance with the provisions of 2 CFR § 200.302.

View Audit 295394

Finding 380645 (2023-001)

Significant Deficiency 2023

The Transit System, Inc.

TX

Questioned Costs Cash Management Matching / Level of Effort / Earmarking § 200.303

The System has contacted the Texas Department of Transportation requesting instructions on refunding the amounts. In addition, they will implement new procedures and controls surrounding the calculation of their request for reimbursement and the handling of insurance proceeds to prevent this from h...

The System has contacted the Texas Department of Transportation requesting instructions on refunding the amounts. In addition, they will implement new procedures and controls surrounding the calculation of their request for reimbursement and the handling of insurance proceeds to prevent this from happening moving forward.

View Audit 295392 Questioned Costs: $1

Finding 380603 (2023-002)

Material Weakness 2023

Survivor Empowerment Center

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking

Corrective Action Plan Finding No. 2023-002 – Salaries and Benefits Not Supported by Proper Time and Effort Documentation Federal Program: Crime Victim Assistance Project No: 220001 and 2020-V2-GX-0017 CFDA No: 16.575 Passed Through: Illinois Coalition Against Domestic Violence and Illinois Coalit...

Corrective Action Plan Finding No. 2023-002 – Salaries and Benefits Not Supported by Proper Time and Effort Documentation Federal Program: Crime Victim Assistance Project No: 220001 and 2020-V2-GX-0017 CFDA No: 16.575 Passed Through: Illinois Coalition Against Domestic Violence and Illinois Coalition Against Sexual Assault Federal Agency: U.S. Department of Justice Condition: During our testwork, we noted the following: • One employee’s timesheets did not reflect the correct allocation percentages determined by the Organization, • Five employees did not have a time and effort certification submitted during the 4th quarter of 2023, and • Two employee timesheets were not signed by the employee. Plan: The Survivor Empowerment Center, Inc. is currently in the process of training a new HR/Payroll Specialist and putting together a step-by-step checklist for completing payroll to ensure all steps are taken. This checklist includes a review of payroll by the Assistant Director. Anticipated Date of Completion: By March 13, 2024 – the next payroll. Name of Contact Person: Susan Hicks, Assistant Director

View Audit 295367

Finding 380600 (2023-001)

Significant Deficiency 2023

Starmont Community School District

IA

Internal Control / Segregation of Duties

Internal control deficiencies: See Finding 2023-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is n...

Internal control deficiencies: See Finding 2023-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible.

View Audit 295352

Finding 380599 (2023-009)

Material Weakness 2023

Madison-Grant United School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-009 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters, Qualified Opinion The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, tha...

FINDING 2023-009 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: Material Weakness, Other Matters, Qualified Opinion The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Chief Financial Officer and reviewed by a second knowledgeable individual; however, this process did not allow for the prevention, or detection and correction of errors prior to submission. Due to the lack of effective internal controls, one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER 1, Year 2 report, which covered the period of October 1, 2020 to June 30, 2021, the School Corporation’s records did not support the data in the report. The lack of controls and noncompliance were isolated to the ESSER I, Year 2 report. Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Supporting documentation of data reported will be retained with each report filed. Anticipated Completion Date: February 2024

View Audit 295346

Finding 380594 (2023-008)

Material Weakness 2023

Madison-Grant United School Corporation

IN

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

FINDING 2023-008 Finding Subject: Education Stabilization Fund - Activities Allowed or Unallowed Summary of Finding: Material Weakness The Elementary and Secondary School Emergency Relief (ESSER) Fund provided funding to States and school districts to combat the effects of the coronavirus, help safe...

FINDING 2023-008 Finding Subject: Education Stabilization Fund - Activities Allowed or Unallowed Summary of Finding: Material Weakness The Elementary and Secondary School Emergency Relief (ESSER) Fund provided funding to States and school districts to combat the effects of the coronavirus, help safely reopen and sustain the safe operation of schools, and to address the impact of the coronavirus pandemic on the nation’s students. States were required to subgrant a portion of their ESSER allocation to local educational agencies (LEA). Prior to LEAs receiving their respective subgrants, LEAs were required to complete an application for ARP ESSER funding, which was submitted to the Indiana Department of Education (IDOE), the pass-through entity for approval. The application included a district level budget identifying how the LEA intended to spend program funds. The School Corporation did not have internal controls in place over payroll disbursements charged to the ESSER grant funds. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Quarterly grant meetings will be held between the CFO, Deputy Treasurer, and Grant writer. This will ensure compliance requirements continue to be met. The CFO now reviews the Org Charge report and signs off before the payroll batch being released to the bank. This report is generated by Payroll and Benefits. Also, this entire report is now included with board claims for board approval rather than a final summary sheet. Anticipated Completion Date: February 2024

View Audit 295346

Finding 380582 (2023-006)

Material Weakness 2023

Madison-Grant United School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Period of Performance § 200.303

FINDING 2023-006 Finding Subject: Special Education Cluster (IDEA) – Activities Allowed or Unallowed, Period of Performance Summary of Finding: Material Weakness The Individuals with Disabilities Act (IDEA) Special Education – Grants to States program provides grant to states, and through them to Lo...

FINDING 2023-006 Finding Subject: Special Education Cluster (IDEA) – Activities Allowed or Unallowed, Period of Performance Summary of Finding: Material Weakness The Individuals with Disabilities Act (IDEA) Special Education – Grants to States program provides grant to states, and through them to Local Educational Agencies (i.e. the School Corporation), to assist them in providing special education and related services to eligible children with disabilities ages 3-21. IDEA’s Special Education – Preschool Grants program provides grants to states, and through them to LEAs to assist them in providing special education and related services to children with disabilities ages three to five and, at the state’s discretion, to twoyear- old children with disabilities who will turn three during the school year. The School Corporation had not properly designed or implemented a system of internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Activities Allowed or Unallowed: The School Corporation did not have internal controls in place over payroll disbursements charged to the special education grants. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Period of Performance: A payroll journal report was generated by the Payroll/Benefits Coordinator and reviewed and approved by the Chief Financial Officer or the Deputy Treasurer to ensure costs charged to the special education grants were within the period of performance. However, there was no documented evidence of the review. Contact Person Responsible for Corrective Action: Bengamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Quarterly grant meetings will be held between the CFO, Deputy Treasurer, and Grant writer. This will ensure compliance requirements continue to be met. The CFO now reviews the Org Charge report and signs off before the payroll batch being released to the bank. This report is generated by Payroll and Benefits. Also, this entire report is now included with board claims for board approval rather than a final summary sheet. Anticipated Completion Date: February 2024

View Audit 295346

Finding 380563 (2023-003)

Material Weakness 2023

Madison-Grant United School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Cash Management § 200.303

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: Material Weakness A cash reimbursement is provided to the School Corporation based on meals served under the School Breakfast Program, National School Lunch Program, and Summer Food Servic...

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: Material Weakness A cash reimbursement is provided to the School Corporation based on meals served under the School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children. The cash reimbursement is to be used for the benefit of the food service program. The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Benjamin Mann Contact Phone Number and Email Address: 765-536-0008 bmann@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The CFO now reviews the Org Charge report and signs off before the payroll batch being released to the bank. This report is generated by Payroll and Benefits. Also, this entire report is now included with board claims for board approval rather than a final summary sheet. Anticipated Completion Date: February 2024

View Audit 295346

Finding 380550 (2023-001)

Significant Deficiency 2023

Paris School District

AR

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions § 200.326

The Paris School District does not dispute the findings that the previous administration did not obtain a written contract that included the prevailing wage rate clause as required by the Davis-Bacon Act for two roofing projects.

View Audit 295335

Finding 380550 (2023-001)

Significant Deficiency 2023

Paris School District

AR

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions § 200.326

Also, the Paris School District did not obtain a performance bond for said roofing projects.

View Audit 295335

Finding 380550 (2023-001)

Significant Deficiency 2023

Paris School District

AR

Equipment & Real Property Management Internal Control / Segregation of Duties Special Tests & Provisions § 200.326

All future projects that require the requirements for Davis-Bacon will be written in the contract and include weekly certified payrolls submitted to the district by the vendors and performance bonds will be secured.

View Audit 295335

Finding 380549 (2023-003)

Significant Deficiency 2023

River Kourt Apartments

OR

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs § 200.318 § 200.320

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all ...

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all other factors to be used in evaluating bids or proposals i. §200.319, Competition requirements will be met with documented procurement actions using strategic sourcing, shared services, and other similar procurement arrangements ii. §200.320 Methods of procurement to be followed. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. The written policies will be updated by 05/01/2024.

View Audit 295334

Finding 380548 (2023-002)

Significant Deficiency 2023

River Kourt Apartments

OR

Questioned Costs HUD Housing Programs Reporting

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HU...

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 2. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance, ShelterCare 3. The anticipated completion date: a. New property accountant was hired in August of 2023.

View Audit 295334

Finding 380547 (2023-001)

Material Weakness 2023

River Kourt Apartments

OR

HUD Housing Programs Eligibility Material Weakness

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/23. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD complia...

Management’s Response and Planned Corrective Actions: 1. The corrective action planned: a. Pinehurst Management was overseeing property through 4/30/23. ShelterCare was assigned as new managing agent 5/1/2023. b. ShelterCare is working to ensure that the onsite manager will be trained in HUD compliance. c. We are currently prioritizing recertifications by oldest first so we are able to catch them up and get the property certifications back on track. d. Monthly review of TRACS reports to ensure recertifications are being completed in a timely manner. 2. The name of the contact person(s) responsible for the corrective action a. Dana Petersen-Crabb, Sr. Director of Housing, ShelterCare b. Amanda Smith, Property Development Manager, ShelterCare 3. The anticipated completion date: a. Monthly review of TRACS reports will be implemented by 10/1/2023. Training was provided to new staff in February of 2024. Recertifications are expected to be completed by June 30, 2024.

View Audit 295334

Finding 380546 (2023-001)

Material Weakness 2023

Corry Memorial Hospital Association D/b/a Lecom Health Corry Memorial

PA

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

Condition The Organization did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Organization erroneously excluded certain transactions from the lost revenue calculation, resulting in lost revenues being overstated $95,765...

Condition The Organization did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. We noted that the Organization erroneously excluded certain transactions from the lost revenue calculation, resulting in lost revenues being overstated $95,765. The Organization reported lost revenues amounting to $471,219 on distributions totaling $925,113. The Organization had excess lost revenues from previous periods available to be used through June 30, 2023 amounting to $1,218,904. Corrective Action Plan Corrective Action Planned: The Organization will update its policies and procedures to ensure the submission undergoes a detailed review and that all points are cleared prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Tim McGahen, Chief Financial Officer Anticipated Completion Date: We anticipate that this will be completed by June 30, 2024.

View Audit 295333

Finding 380528 (2023-001)

Significant Deficiency 2023

Claremont Unified School District

CA

Eligibility HUD Housing Programs School Nutrition Programs

II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 50000 - ELIGIBILITY Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. M...

II. FEDERAL FINDINGS AND QUESTIONED COSTS 2023-001 50000 - ELIGIBILITY Management's Response: We concur. View of Responsible Officials and Corrective Action Plan In the 2023-24 school year, Nutrition Services has implemented an additional step when processing meal applications to improve accuracy. Meal applications are verified a total of three times. The Nutrition Specialist is the Determining Official, the Director is the Confirming Official, and either the Secretary or Clerk is the Verifying official. Each official reviews the application for accuracy. Name of responsible individual: Brenda Zarate Implementation Date: 7/1/2023

View Audit 295319

Finding 380526 (2023-001)

Significant Deficiency 2023

Continuum of Care, Inc. and Affiliates

CT

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon...

Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheet for the payroll disbursements tested. Questioned costs: None Context: The timesheet for 4 out of 4 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: Yes Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Although other controls and reviews around compensation help safeguard and mitigate compensation errors, the property manager will ensure that all time sheets are properly approved prior to payment as a first line of internal controls. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: May 30, 2024.

View Audit 295318

Finding 380524 (2023-001)

Significant Deficiency 2023

Margaret B. MacK Supportive Housing Corporation Hud Proj. #017-Hd038

CT

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management establish the residual receipt account and make the required deposit as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the ...

Supportive Housing for Persons With Disabilities – Assistance Listing No. 14.181 Recommendation: We recommend that management establish the residual receipt account and make the required deposit as soon as possible. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A residual receipt account has been established. Required deposit will be made by May 30, 2024. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Required deposit will be made by May 30, 2024.

View Audit 295316

Finding 380523 (2023-003)

Material Weakness 2023

National Indian Council on Aging, Inc.

NM

Internal Control / Segregation of Duties

A policy and procedure regarding cash disbursements was written and presented to the Executive Director and the management team in June 2023. NICOA implemented controls and procedures recommended by the auditors. The policy was revised, and a copy of the policy was provided to the auditors. Controls...

A policy and procedure regarding cash disbursements was written and presented to the Executive Director and the management team in June 2023. NICOA implemented controls and procedures recommended by the auditors. The policy was revised, and a copy of the policy was provided to the auditors. Controls have been implemented and improvements made in the handling of disbursements. NICOA is working on correcting the problem even further and making sure to have tied internal controls. A Financial Director was hired in May 2023, immediately realized that there were problems with internal controls and made management aware that there was internal control problems; NICOA has implemented some recommendations. Under the Acting Executive Director, action on the recommendations has been implemented effective immediately. New accounting and credit card policies were implemented on July 1, 2023, addressing Internal controls.

View Audit 295291

Finding 380516 (2023-003)

Significant Deficiency 2023

City of Ottawa

IL

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment

Corrective Action Plan: Management concurs with the Auditor’s recommendation and will review with the third-party North Central Illinois Council of Governments (NCICG) to establish appropriate City monitoring and review. Person(s) Responsible (Name, title): Donald Harris, City Treasurer and Shelly...

Corrective Action Plan: Management concurs with the Auditor’s recommendation and will review with the third-party North Central Illinois Council of Governments (NCICG) to establish appropriate City monitoring and review. Person(s) Responsible (Name, title): Donald Harris, City Treasurer and Shelly Munks, City Clerk Timing for Implementation: 7/31/2024

View Audit 295284

Finding 380491 (2023-001)

Significant Deficiency 2023

Postville Community School District

IA

Internal Control / Segregation of Duties

Internal control deficiencies: See Finding 2023-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is n...

Internal control deficiencies: See Finding 2023-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible.

View Audit 295256

Corrective Action Plans

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