Corrective Action Plans

Finding 58486 (2022-007)

Material Weakness 2022

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option I to calculate lost revenue for its subsidiary, which consists of reporting quarterly net revenue by payor during the period of availability. Net revenue was determined by projecting payor deductions instead of using actual deductions as required by the terms and conditions of the award. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58485 (2022-006)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option II to calculate lost revenue for its subsidiary, which consists of a comparison of actual results during the period of availability to the approved budget in 2020 and 2021. The budget was required to be approved by March 27, 2020. The budget used for 2021 and 2022 was not approved by the required date. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58484 (2022-005)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.327 § 200.328

Material Weakness: Criteria: RWHS must establish and maintain effective internal control over federal awards that provides reasonable assurance that RWHS is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2...

Material Weakness: Criteria: RWHS must establish and maintain effective internal control over federal awards that provides reasonable assurance that RWHS is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the quarterly revenue on an actual and budgeted basis to be reported to the federal agency by March 31, 2023. Condition: RWHS submitted instances of inaccurate actual revenue for quarters 3 and 4 of 2021 and 2022 and inaccurate budgeted revenue for quarters 2 and 3 of 2021. Planned Corrective Action: Management will implement procedures to ensure that the required revenue totals are reported accurately in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: December 31, 2023

View Audit 54656

Finding 58481 (2022-001)

Material Weakness 2022

Municipality of Skagway

AK

Questioned Costs Special Tests & Provisions Material Weakness

Finding 2022-001 ? Special Tests and Provisions ? Internal Control Over Compliance ? Material Weakness in Internal Control Over Financial Reporting and Material Noncompliance Issue: A missing application from the audit sample was shredded in error before being scanned into the patient?s Electronic H...

Finding 2022-001 ? Special Tests and Provisions ? Internal Control Over Compliance ? Material Weakness in Internal Control Over Financial Reporting and Material Noncompliance Issue: A missing application from the audit sample was shredded in error before being scanned into the patient?s Electronic Health Records (EHR) chart, resulting in a documentation gap. Objective: To prevent the recurrence of missing sliding fee applications by implementing a revised process that ensures all applications are properly documented and stored in the Electronic Health Records (EHR) system. Corrective Action Plan: Reception staff will continue to manage applications and supporting documentation, but once an application is complete and scanned to the patient?s chart, it will be stamped ?SCANNED? and passed to the Accounts and Benefits Specialist (ABS). The ABS will verify that the packet has been added to the patient?s EHR chart and the correct slide is placed on the account. Only application packets that are stamped ?SCANNED? will be shredded by the ABS. If the packet is not stamped, another review will be done by ABS to ensure a complete record in EHR prior to shredding. All incomplete applications will continue to be kept in a physical file by reception staff with date stamps and notes of what documentation is missing. Once an application is complete it will follow the steps outlined above. Expected Completion Date: Fiscal Year 2023

View Audit 54032 Questioned Costs: $1

Finding 58478 (2022-001)

Material Weakness 2022

Elbert County, Colorado

CO

Subrecipient Monitoring Internal Control / Segregation of Duties Material Weakness

Finding 2022-001: Material Weakness, Internal Control Over Compliance and Compliance Person(s) Responsible: Tiffany Hermes, Finance Manager Anticipated Completion Date: 9/30/2023 Corrective Action Plan: The County has taken steps to restructure and increase the in-house capabilities of the finan...

Finding 2022-001: Material Weakness, Internal Control Over Compliance and Compliance Person(s) Responsible: Tiffany Hermes, Finance Manager Anticipated Completion Date: 9/30/2023 Corrective Action Plan: The County has taken steps to restructure and increase the in-house capabilities of the finance department and overall County management. Several hiring actions have occurred, and the finance department is now full. ? There are steps in place now pertaining to internal controls which include having two employees with access to federal reports and submission capability. ? Upon an employee leaving, a structure will be in place to passalong the access to the correct position for future reporting.

View Audit 56078

Finding 58477 (2022-001)

Significant Deficiency 2022

Derry Housing & Redevelopment Authority

NH

HUD Housing Programs Internal Control / Segregation of Duties § 200.305 § 200.514

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Melody Ackerman, Executive Director Corrective Action: The Derry Housing and Redevelopment Authority will take the following actions to address finding 2022-001; The Derry Housing and Redev...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Melody Ackerman, Executive Director Corrective Action: The Derry Housing and Redevelopment Authority will take the following actions to address finding 2022-001; The Derry Housing and Redevelopment Authority (DHRA) will select an accurate Rent Reasonableness system to use. Once an accurate NH022 Rent Reasonableness system has been selected, the PHA must update HCV Administrative Plan, including receiving Board approval, to document the use of this new system. The PHA must perform Rent Reasonableness determinations utilizing the Board approved methodology on all currently leased vouchers. The DHRA expects to have all corrections in place by December 1, 2023.

View Audit 56077

Finding 58473 (2022-001)

Significant Deficiency 2022

Mississippi Food Network, Inc.

MS

Eligibility Internal Control / Segregation of Duties

Findings: 2022-001 MISSISSIPPI FOOD NETWORK Name of Responsible Official: Theodora Ann Rowan, Director of Accounting/Information Technology Anticipation Completion Date: 06/30/2023 Network's Response: The Network plans to enhance an existing internal control to ensure the agency files are complete w...

Findings: 2022-001 MISSISSIPPI FOOD NETWORK Name of Responsible Official: Theodora Ann Rowan, Director of Accounting/Information Technology Anticipation Completion Date: 06/30/2023 Network's Response: The Network plans to enhance an existing internal control to ensure the agency files are complete with all the required documentation. The Accounting Department will perform a quarterly review of the files on a rotation basis. Subsequent to June 30, 2022, the Network hired a new Director of Accounting/Information Technology who will be responsible for this internal control.

View Audit 55294

Finding 58467 (2022-002)

None 2022

Elm Manor Homes, INC 051-11208 Fka.#s 051-Eh102-Wah/l8 &051eh164wahl8

VA

Special Tests & Provisions HUD Housing Programs Internal Control / Segregation of Duties

Identifying Number: Section 223(F), HUD Insured Mortgage - CFDA 14.155 (Special Tests and Provisions) Finding: 2022-02: In conjunction with our audit in acco...

Identifying Number: Section 223(F), HUD Insured Mortgage - CFDA 14.155 (Special Tests and Provisions) Finding: 2022-02: In conjunction with our audit in accordance with the requirements established by the U.S. Department of Housing and Urban Development, tenant security deposits are required to be returned within 30 days of the tenant's move-out date. However, in performing procedures to ascertain the accuracy of the return of security deposits, we noted the security deposit returned to one tenant was more than 30 days after move-out. We recommend that security deposits be returned within 30 days of the tenant's move-out date. Corrective Action Taken or Planned Management has implemented steps to ensure that future security deposit refunds are made within the 30 day requirement.

View Audit 55291

Finding 58464 (2022-003)

Significant Deficiency 2022

Independent School District No. 833

MN

Questioned Costs Internal Control / Segregation of Duties Special Tests & Provisions

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-003 Internal Control Over Compliance and Noncompliance With Special Tests and Provisions Requirement...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND REPORTABLE INSTANCE OF NONCOMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-003 Internal Control Over Compliance and Noncompliance With Special Tests and Provisions Requirements Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. The District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. Corrective Action Plan Actions Planned ? The District will review its procedures relating to special tests and provisions requirements specifically relating to eligible equipment for which the District could seek reimbursement to ensure compliance in the future with any additional federal awards. Official Responsible ? Kris Blackburn, Fiscal Services Director. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Fiscal Services Director will ensure appropriate controls are in place to verify the District?s compliance with federal special tests and provisions requirements.

View Audit 55289 Questioned Costs: $1

Finding 58463 (2022-002)

Significant Deficiency 2022

Independent School District No. 833

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? FEDERAL ALN 21.027 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requ...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? FEDERAL ALN 21.027 2022-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ? 180 requires Independent School District No. 833 (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the coronavirus state and local fiscal recovery funds federal program. The District did not have sufficient controls in place within its coronavirus state and local fiscal recovery funds federal program to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned ? The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible ? Kris Blackburn, Fiscal Services Director. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Fiscal Services Director will ensure appropriate controls are in place to verify that any vendor with which the District contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.

View Audit 55289

Finding 58456 (2022-001)

Significant Deficiency 2022

Iowa Oncology Research Association

IA

Internal Control / Segregation of Duties

The lack of segregation of duties will remain a finding until the cost to alleviate the finding provides a benefit to the Organization.

View Audit 54409

Finding 58453 (2022-003)

Material Weakness 2022

North Spencer County School Corporation

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree t...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree to the accounting records. The annual reports prepared by the Corporation Treasurer will be provided to the Director of Learning who oversees the Elementary and Secondary School Emergency Relief (ESSER) grant to review and approve the amounts reported are accurate. After review and approval from the Director of Learning, the annual reports will be submitted by the Corporation Treasurer. Anticipated Completion Date: May 2023

View Audit 54408

Finding 58450 (2022-002)

Significant Deficiency 2022

Charles Drew Health Center, Inc.

NE

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

CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the slidi...

CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the sliding discount schedule. This process began February 28, 2023. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS. This process began February 28, 2023. 3. Management will implement a process to ensure that all reviews and audit corrections are performed by a person other than the person performing the review and all adjustments to patient accounts are reviewed subsequent to processing. Anticipated completion date is June 30, 2023.

View Audit 49524

Finding 58446 (2022-003)

Significant Deficiency 2022

Volunteer Homes for Elderly

TN

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 ...

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 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. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT None Finding No. 2022 ? 003: Ineffective oversight and operation of internal controls over compliance by management Volunteer Homes for Elderly, Inc's managers did not follow all HUD requirements when going through the tenant recertification process. The tenant files tested for internal controls over compliance contained multiple deficiencies including missing copy of social security card in order to verify social security number; missing income verification; missing Ethnic and Racial Data conformation; incorrect calculation of tenant assets; incorrect income used on HUD Form 50059, and missing tenant signature and date on Resident Rights and Responsibilities acknowledgment. Criteria: According to HUD Handbook 4350.3: 1. All applicant and tenant household members must disclose and provide verification of the complete and accurate social security number assigned to them except for those individuals who do not contend eligible immigration status. Owners must include verification documentation in the tenant file. Owners must gather data about the race and ethnicity of applicants and tenants so that HUD can easily spot possible discrimination, track racial or ethnic concentrations, and focus enforcement actions on owners with racially or ethnically identifiable properties. 4. Owners must verify all income assets, expenses, deductions, family characteristics, and circumstances that affect family eligibility or level of assistance: for savings accounts, use the current balance and for checking accounts. use the average balance for the last six months. 5. Annual income is defined as all amounts anticipated to be received from a source outside the family during the 12?month period following admission or annual recertification and owner calculates projected annual income by annualizing current income. 6. Owners must provide applicants and tenants with a copy of the Resident Rights and Responsibilities brochure at move-in and annual recertification and all family members at least 18 years of age must acknowledge receipt of brochure by signing and dating the acknowledgement. Cause of Condition: The management agent did not have systems in place to ensure managers know of and are complying with ail HUD requirements pursuant to the HUD Handbook 4350.3. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper procedures in place to ensure managers know of applicable HUD requirements and are complying with HUD requirements. Action Taken: Management agent will provide additional training on HUD requirements to managers during their annual manager's training and implement procedures to ensure managers are complying with requirements pursuant to' HUD Handbook 4350.3.

View Audit 56038

Finding 58445 (2022-002)

Significant Deficiency 2022

Volunteer Homes for Elderly

TN

HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 ...

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 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. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT None FINDINGS-FEDERAL AWARD PROGRAMS AUDITS Finding No. 2022 ? 002: Ineffective oversight and operation of internal controls over compliance by management Volunteer Homes for Elderly, Inc?s managers are not keeping EIV data as required by HUD. After being informed by the management agent to destroy EIV data that is greater than three years after tenancy, managers proceeded to destroy EIV data before the retention period expired. Criteria: According to HUD Handbook 4350.3, owners must retain EIV data in the tenant file for the term of tenancy plus three years. Once retention period expires, owners must dispose of EIV data in proper manner. The requirements of EIV are included in chapter 9 of the HUD handbook. Cause of Condition: The managers are not following requirements for EIV data pursuant to the HUD Handbook 4350.3. Recommendation: Auditor recommends management agent provide additional training to managers regarding retention period of EIV data and put proper controls in place to ensure the managers are complying with HUD requirements. Action Taken: Management agent will remind managers of retention period of EIV data required by HUD and provide additional training at the annual manager's training.

View Audit 56038

Finding 58444 (2022-001)

Significant Deficiency 2022

Volunteer Homes for Elderly

TN

HUD Housing Programs Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 ...

CORRECTIVE ACTION PLAN Volunteer Homes for Elderly, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: October 1, 2021 - September 30, 2022 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. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS-FINANCIAL STATEMENT AUDIT None FINDINGS-FEDERAL AWARD PROGRAMS AUDITS CORRECTIVE ACTION COMPLETED: Finding No. 2022 ? 001: Ineffective oversight and operation of internal controls over compliance by management Volunteer Homes for Elderly, Inc. had a Management Review (MOR) during the period under audit. The MOR had a significant number of findings in the Leasing and Occupancy section. The findings were related to the following: missing HUD required information on tenant selection plan, house rules, Violence Against Women Act (VAWA) emergency plan, eviction and rejection notices, tenant applications, marketing materials, HUD Forms, and EIV policies and procedures; EIV requirements not executed as required; new hire detail reports not filed correctly; tenant files missing HUD required documents; tenant file documents missing signatures and dates from required parties; incorrect information listed on HUD Form 9887/A; incorrect or miscalculated income, assets, and medical expenses used on HUD Form 50059; and tenants charged estimates for damages at move-out instead of actual costs. Criteria: HUD compliance requirements can be found in the HUD Handbook 4350.3 and VAWA requirements can be found at 24 CFR 5.2005 and FR?5720?F-03. Cause of Condition: Management agent and managers not aware of requirements, not following procedures properly, does not have proper procedures in place, oversight, and error. Action Taken: Management agent has updated all documents to include the missing HUD required information, sent out correspondence to managers to inform them of the requirements that were not previously followed, had managers correct tenant file deficiencies noted in the MOR, and will provide additional training to the managers at the annual on-site manager's training. Auditor validates the actions taken. Recommendation: Through compliance testing audit procedures, auditor reviewed the corrective action plan, corrections, and correspondence regarding the MOR findings and therefore. validated the actions taken. In addition, auditor recommends management agent put additional procedures in place to periodically review HUD Handbook 4350.3, periodically review property documents to ensure they are up to date with HUD requirements, and ensure managers know and are complying with HUD requirements.

View Audit 56038

Finding 58442 (2022-001)

Significant Deficiency 2022

Deerfield Community School District

WI

Internal Control / Segregation of Duties

Lack of Segregation of Duties Condition: The responsibility for the District?s bookkeeping and accounting functions is assumed by a limited number of individuals. The Business Manager enters and approves journal entries and reconciles all bank accounts. Criteria: Internal controls should be in...

Lack of Segregation of Duties Condition: The responsibility for the District?s bookkeeping and accounting functions is assumed by a limited number of individuals. The Business Manager enters and approves journal entries and reconciles all bank accounts. Criteria: Internal controls should be in place that provide adequate segregation of duties and reduce overlapping accounting functions, especially in cash receipts and disbursements. In addition, those functions should be segregated from those overseeing overall finances. Cause: The District has determined that hiring additional staff to perform separate accounting duties would be too costly and not an effective use of resources. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Recommendation: The District should be aware of the need for separation of duties and provide for as much separation of duties as feasible in the circumstances. Response: Management of the District is aware that the current number of accounting staff does not allow for full segregation of duties. Segregation of duties is enhanced whenever possible and the Board of Education and management assumes an active roll through monthly review of receipts and disbursements and monthly financial reports. The Superintendent and Business Manager are in constant communication regarding the District?s finances. The Superintendent is not involved in processing day to day financial transactions. Contact Person: Doreen Treuden Anticipated Completion: Not Applicable

View Audit 55514

Finding 58441 (2022-101)

Significant Deficiency 2022

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBE...

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O'Neill, Director 2. Corrective action planned: a. For 2 of 40 providers files tested, menus were clerically inaccurate and did not support the meals claimed. The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts. See BJ Enterprises Procedures for Reading Menus, Section D, #6. b. For 1 of 40 provider files tested, meals were claimed for the provider's own child, when the provider was not eligible for free/reduced price meals. The menu reader must use the most current "Claiming Own" report while they are menu reading. The income applications have to be approved by the Assistant Director or Director prior to the menus being read. The menu reader will use this list, as well as the Master List when reading the menus. The Area Coordinators will be retrained to ensure that the provider who is claiming their own children qualify to do so. See BJ Enterprises Procedures for Reading Menus, Section C, #5. c. For 2 of 40 provider files tested meals were claimed when the provider's children were the only children present. This occurred when the day care children were disallowed. The Area Coordinators will be re-trained to disallow the day care providers own children when meals are disallowed for all of the day care children. See BJ Enterprises Procedures for Reading Menus, Section C, #5. d. For 1 of 40 provider files tested, meals were claimed outside of the current claim month. The Area Coordinators will be re-trained to disallow meals on the front end or the back end of the month. See BJ Enterprises Procedures for Reading Menus, Section B, #2. e. For 1 of 40 provider files tested, meals were claimed when the child was not indicated as being present for the meal. The times in and out were not on the day that was claimed. The Area Coordinators will be re-trained to disallow meals when the time in and outs are not written on the menu. See 8 J Enterprises Procedures for Reading Menus, Section C, #4. f. For 1 of 40 provider files tested, meals were claimed when no menu components were listed on the menu. The Area Coordinators will be re-trained to disallow meals when thy have no components listed on the menu. See BJ Enterprises Procedures for Reading Menus, Section B, #3. All of the menu mistakes were on paper menus. We are encouraging everyone to start claiming on computerized menus (KidKare) because there are less or no mistakes on those menus. 3. Anticipated completion date: June 30, 2023

View Audit 55181

Finding 58440 (2022-002)

Significant Deficiency 2022

Independent School District No. 911

MN

Internal Control / Segregation of Duties Special Tests & Provisions Procurement, Suspension & Debarment

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only see...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? FEDERAL COMMUNICATIONS COMMISSION, EMERGENCY CONNECTIVITY FUND PROGRAM ? FEDERAL ALN 32.009 2022-002 Internal Control Over Compliance With Special Tests and Provisions Finding Summary 47 CFR ? 54.1711 requires that the District only seek support for eligible equipment provided to students and school staff who would otherwise lack connected devices sufficient to engage in remote learning. During our audit, we noted the District did not have sufficient controls in place within its Emergency Connectivity Fund Program to assure compliance with federal special tests and provisions requirements. We noted that the District requested federal reimbursement for purchased technology devices prior to those devices being used or deployed, and thus not yet meeting the definition of eligible equipment for which the District could seek reimbursement. Corrective Action Plan Actions Planned ? The finding resulted from a timing issue caused by unfamiliarity with a new federal program. The District subsequently deployed all devices for which it was reimbursed to students in accordance with the unmet needs defined and approved in its award applications. The District understands the applicable guidance and will ensure that future reimbursement requests under the Emergency Connectivity Fund Program will not be made until after the equipment has been placed in service. Official Responsible ? Director of Finance and Operations, Christopher Kampa. Planned Completion Date ? March 31, 2023. Disagreement With or Explanation of Finding ? The District is in agreement with this finding. Plan to Monitor ? The District?s Director of Finance and Operations, Christopher Kampa, will assure appropriate internal controls are in place to verify future compliance with special tests and provisions requirements for the Emergency Connectivity Fund Program.

View Audit 55911

Finding 58438 (2022-001)

None 2022

Emmanuel College

GA

Questioned Costs Special Tests & Provisions Student Financial Aid

Emmanuel College Audit Response Finding number 2022-001 from the 2022 audit has been copied below with the management response and corrective action plan provided. EMMANUEL COLLEGE SCHEDULE OF FINDINGS AND QUESTIONED COSTS JUNE 30, 2022 Condition: Out of a sample of 108 students there were 20 who ...

Emmanuel College Audit Response Finding number 2022-001 from the 2022 audit has been copied below with the management response and corrective action plan provided. EMMANUEL COLLEGE SCHEDULE OF FINDINGS AND QUESTIONED COSTS JUNE 30, 2022 Condition: Out of a sample of 108 students there were 20 who withdrew. We decided to test all 20 of those students as it related to return of Title IV funds. Return of funds were sent in by the required date except for two instances. One was late due to the Thanksgiving Holiday. The school was closed on that Thursday and Friday, so the funds were not submitted until the following Monday. This was not a big deal; however, the other instance was simply late by 4 days and no Holidays were involved. Cause: Simply an oversight in which the date simply slipped by them. Effect: The Department of Education received the transferred return of funds 4 days later than they were required to be deposited into the SFA account. Recommendation: College management should design and implement procedures to ensure that there are checks and balances to make sure that when a student withdraws and the return of funds are calculated that the required return date is flagged and sent to whomever is responsible for submitting those funds to the SFA account. Management Response and Corrective Action Plan: Financial Aid personnel will utilize a built in Return to Title IV funds feature of the financial aid software, PowerFaids, to function as a quality assurance measure for Accounting Office staff. The PowerFaids function archives the date of withdrawal and calculates the deadline for return of funds. This feature will allow for quality assurance reports to be pulled no less than a week before the deadline so that Financial Aid staff can serve as an accountability partner for accounting staff in ensuring funds are returned in a timely fashion and in compliance with all federal guidelines. Contact Responsible for Corrective Action: Donna Quick, Vice President for Enrollment, 706-245-2872

View Audit 55512 Questioned Costs: $1

Finding 58435 (2022-003)

Significant Deficiency 2022

Tucson Unified School District No. 1

AZ

Questioned Costs Subrecipient Monitoring Reporting

2022-003 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to review its current procedures over the review of contracts to ensure prevailing wage rates clauses are included in the contract and implement a monitoring control to ensure certified pa...

2022-003 Education Stabilization Fund ? Assistance Listing No. 84.425 Recommendation: We recommend the District to review its current procedures over the review of contracts to ensure prevailing wage rates clauses are included in the contract and implement a monitoring control to ensure certified payrolls are submitted by the contractor or subcontractor in a timely manner as required by the regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For all Requests for Proposals (RFP), Invitations for Bid (IFB), and Requests for Quotations (RFQ), the District provides a ?Special Requirements: Federal Requirements? section in all of the terms and conditions that prospective vendors must review. All vendors are required to acknowledge that they read, understand, and will abide by the various Federal requirements. Among them, a clause of building projects states, ?Davis-Bacon Act ? the OFFEROR shall complete with the Davis-Bacon Act (40 U.S.C. 276a to 276a-7) as supplemented by the Department of Labor regulations (29 CFR Part 5).? Any prospective vendor is required to maintain records for the operations under the awarded contract for a period of not less than five (5) years for the District?s review. The District is currently identifying construction project vendors and requesting documentation to show evidence that the vendors met the requirements of Davis-Bacon. Davis-Bacon requirements have been implemented since July 1, 2022, and missing documentation from vendors will be collected by June 30, 2024. Name of the contact person responsible for corrective action: Ricky Hernandez, Chief Financial Officer Planned completion date for corrective action plan: Process was implemented by June 30, 2022. Vendors with missing documentation will be collected by June 30, 2024.

View Audit 55907 Questioned Costs: $1

Finding 58431 (2022-002)

Material Weakness 2022

The Harry and Jeanette Weinberg Gardens at Bedford, INC

MD

HUD Housing Programs Cash Management Internal Control / Segregation of Duties

Finding 2022-2 a. Comments on the Finding and Each Recommendation Management agrees with the finding. b. Action(s) Taken or Planned on the Finding The Residual Receipts deposit was not made timely due to a turnover in staff. Management has trained all accounting staff on this process and

View Audit 55113

Finding 58429 (2022-002)

Significant Deficiency 2022

Lutheran Seniorlife

PA

Procurement, Suspension & Debarment Reporting Significant Deficiency

2022-002 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. ...

2022-002 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. These funds may not be used to reimburse expenses of losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Organization's internal controls over reporting were not effective. Context: During the audit, it was determined that one out of 13 expenditures selected for testing did not agree to the supporting payment. Recommendation: We recommend expenditures only be allocated to Provider Relief Funds after they have been paid. Action taken in response to finding: Management acknowledges the error in the report and for future reporting periods will verify expenditures have been paid before reporting. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58428 (2022-001)

Significant Deficiency 2022

Lutheran Seniorlife

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-001 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. ...

2022-001 Federal agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Fund Assistance Listing #: 93.498 Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. These funds may not be used to reimburse expenses of losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Organization's internal controls over reporting were not effective. Context: During the audit, it was determined that on three out of five reports selected for testing, lost revenue was overstated due to differences between revenue reported under the actual revenue method (option one) for reporting lost revenue and the underlying internal financial information. Recommendation: We recommend management implement additional procedures to review reported revenue before submitting reports and adjust the system report used to compile the revenue information to ensure it is correct and reflects the utilization of Provider Relief Funds to replace lost revenue. Action taken in response to finding: Management acknowledges the error in selecting an incomplete management revenue report for reporting purposes. For future reporting periods, management will correct the management report utilized and ensure it balances with total revenues. Management will correct the amounts report for 2019 through 2022 beginning with Provider Relief Funds reporting period #4. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Finding 58427 (2022-004)

Significant Deficiency 2022

Lutheran Seniorlife

PA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-004 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: REAC Inspection Resul...

2022-004 Federal agency: U.S. Department of Housing and Urban Development Federal Program Title: Mortgage Insurance ? Nursing Homes, Intermediate Care Facilities, Board and Care Homes, and Assisted Living Facilities Assistance Listing #: 14.129 Criteria or specific requirement: REAC Inspection Results Condition: St. John received a REAC inspection score of less than 31, which denotes the property has physical deficiencies that do not meet contractual obligations to HUD. Context: Results of REAC inspection 613308. Recommendation: St. John should work to address all REAC inspection findings. Action taken in response to finding: Subsequent to this survey, the facility incurred significant flooding, which required immediate action. Due to this, St. John did not have the ability to address the findings from the survey. With a protracted insurance claims process and the impact of Covid-19 on building operations, work on the outstanding deficiencies has been delayed. Due to the risk to residents and staff, all outside visitors including maintenance contractors and other vendors has been limited for a number of periods during the pandemic during FY21. Management completed an assessment of the facility?s use and has begun a repositioning plan to bring new living options into the building. In order to complete the needed improvements to the building, St. John has completed a refinancing of its existing HUD debt and negotiated a construction loan to fund the improvements. The closing on the refinancing of the existing HUD loan and the construction loan took place on July 8, 2021. Name of contact person responsible for corrective action: Jeffrey Carraway

View Audit 55905

Corrective Action Plans

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