Corrective Action Plans

2022-003 Controls Over Activities Allowed/Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the progr...

2022-003 Controls Over Activities Allowed/Allowable Costs Recommendation: The Organization should review their established policies and procedures for effectiveness and ensure all employees adhere to all established procedures. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: United Way of Acadiana has welcomed a new Finance Director with experience in establishing internal controls. We are committed to implementing comprehensive internal controls that encompass enhancing financial reporting processes to ensure accuracy, transparency, and compliance with regulatory standards; budget oversight, risk management and expenditure and cash flow management.

View Audit 24188

Finding 35356 (2022-003)

Significant Deficiency 2022

Boys & Girls Clubs of Central Florida, Inc.

FL

Internal Control / Segregation of Duties § 200.403 § 200.430

Management is in agreement with this finding and was aware of the Organization?s manual process to approve and store physical copies of pay rate approval, which could potentially create risk of losing physical copies. In September 2022, the Organization has modified this process to allow managers to...

Management is in agreement with this finding and was aware of the Organization?s manual process to approve and store physical copies of pay rate approval, which could potentially create risk of losing physical copies. In September 2022, the Organization has modified this process to allow managers to virtually approve and store digital copies of pay rate documentation.

View Audit 23844

Finding 35355 (2022-002)

Material Weakness 2022

Agency for Substance Abuse Prevention, Inc.

AL

Reporting Internal Control / Segregation of Duties

Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective ...

Material Adjustments Description of Finding: The auditor found that The Entity relied on auditors to propose entries after audit procedures and had not recorded entries needed at the time of the audit. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: During the fiscal year ending September 30, 2022, the Entity employed the services of an experienced contract accountant. Performance was evaluated regularly and the decision was made to terminate her services for inadequate performance and a new accountant was hired internally. Management has provided training to the new accountant and has coordinate processes with external auditor to insure accurate interim reporting in the future. The Entity will continue to incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements, and increase the accuracy of interim financial reports used by management.

View Audit 29962

Finding 35354 (2022-001)

Material Weakness 2022

Agency for Substance Abuse Prevention, Inc.

AL

Internal Control / Segregation of Duties Reporting Subrecipient Monitoring

Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with...

Segregation of Duties: Description of Finding: The auditor found that duties were not segregated in a number of areas where small adjustments to the policies of the Entity could help to further facilitate this important control. Statement of Concurrence or Nonconcurrence: Management concurs with this finding. Corrective Action: Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.

View Audit 29962

Finding 35342 (2022-002)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, su...

Finding 2022-002 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. Specifically with these changes, grant accounting duties are also transitioning to the MCHS grant accounting team which extends MCHS system of controls over grant accounting to MMC-Dickinson to ensure accurate and timely completion of the Schedule. Proposed Completion Date: December 31, 2023

View Audit 24187

Finding 35341 (2022-003)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such...

Finding 2022-003 Name of Contact Person: Debra Hansen, Accounting Manager ? Grants and Gifts Corrective Action Plan: Effective May 2023, MMC ? Dickinson converted to the MCHS, Inc accounting systems and its accounting staff fully joined the MCHS, Inc centralized accounting team by August 2023, such that the MCHS system of controls now extend to MMC-Dickinson. With these changes, the MCHS Treasury department will include MMC-Dickinson and this debt in their system of controls and processes which includes monitoring the debt and related reserve accounts for compliance with debt service reserve requirements. Proposed Completion Date: December 31, 2023

View Audit 24187

Finding 35340 (2022-004)

Significant Deficiency 2022

Marshfield Clinic Health System, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work wa...

Finding 2022-004 Name of Contact Person: Dan Fischer, Internal Consultant (former Controller) Corrective Action Plan: In early 2022, the team calculating physician compensation costs eligible for reporting in the HRSA portal experienced turnover of staff and thorough review of new staff?s work was not completed for several months. Although expenses were overstated in the portal, the grant was not overcharged as lower expenses reported for physician compensation costs would have been replaced by increasing the amount related to additional eligible lost revenues. Management will implement review procedures for eligible physician compensation costs to ensure expenditures to the portal are accurate. Proposed Completion Date: December 31, 2023

View Audit 24187 Questioned Costs: $1

Finding 35327 (2022-003)

Significant Deficiency 2022

Pennsauken Lutheran Housing, INC

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file aud...

Planned Corrective Actions: We will re-enforce the use of the mov in/recertification file checklist as a tool for project managers to utilize. We will also conduct at a minimum, semiannual in-house refresher sessions. In addition, we will conduct file reviews for move ins and perform random file audits on annual recertifications.

View Audit 24060

Finding 35322 (2022-002)

Material Weakness 2022

Sweeny Hospital District

TX

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

We are in receipt of the findings required to be reported by the single audit for Period 2 and Period 3 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management d...

We are in receipt of the findings required to be reported by the single audit for Period 2 and Period 3 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. Subsequent to the completion of the FY 2021 single audit and the completion of reporting for periods 2 and 3, the district has prioritized the development of policies over financial reporting processes for all future periods of PRF reporting and auditing. The district will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The hospital CEO, Kelly Park, will oversee this to ensure that this is accomplished. The district will also provide its? consultants and information to be submitted to HRSA for accuracy. The district has already implemented these new procedures for period 4 reporting, and is confident that all future submissions will be correct. The Corrective Action Plan will be implemented by September 30, 2023.

View Audit 24008

Finding 35285 (2022-001)

Significant Deficiency 2022

City of Kearney, Nebraska

NE

Internal Control / Segregation of Duties Reporting Significant Deficiency

Planned Corrective Action: It is cost prohibitive for the City of Kearney to hire sufficient personnel in order to assign responsibilities in such a way that different employees handle different portions of a transaction. However, the City of Kearney will evaluate the distribution of duties to cur...

Planned Corrective Action: It is cost prohibitive for the City of Kearney to hire sufficient personnel in order to assign responsibilities in such a way that different employees handle different portions of a transaction. However, the City of Kearney will evaluate the distribution of duties to current employees and closely monitor all accounting functions.

View Audit 24775

Finding 35284 (2022-001)

Significant Deficiency 2022

Aspirus, Inc.

WI

Internal Control / Segregation of Duties Cash Management Eligibility

Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Ba...

Response: At the time of sending the claim to HRSA the patient did not have other insurance coverage. Subsequently we received information that the patient had other coverage. This information was received by the Financial Clearance department but there was a lack of communication to the Credit Balance Manager as provided for in our process. Although the Credit Balance team would have found and refunded the money to HRSA after the other insurance paid through their normal credit review process, this was not yet completed at the time of the audit. There is an opportunity to increase the timeliness of the refunding process as addressed in our action plan. Corrective Action Plan: ? Refund HRSA for overpayments found during audit ? Completed on 3/13/2023 and 3/15/2023, respectively. ? Reeducation to Financial Clearance team to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as receive information. ? Education and process change with Initial Claims Team, who also reviews coverage changes, to notify Credit Balance Manager of change of coverage for HRSA accounts as soon as they receive. ? Explore Epic build to route accounts with HRSA coverage change to a Credit Balance WQ to be promptly worked.

View Audit 24698

Finding 35246 (2022-001)

Significant Deficiency 2022

Durand Community Unit School District No. 322

IL

Internal Control / Segregation of Duties

The district will continue to have a second individual review all monthly bank statements, reconciliations, and treasurer's reports. The district will designate someone besides the Treasurer to review accounts payable checks prior to mailing them and stamp them with the Superintendent's signature so...

The district will continue to have a second individual review all monthly bank statements, reconciliations, and treasurer's reports. The district will designate someone besides the Treasurer to review accounts payable checks prior to mailing them and stamp them with the Superintendent's signature so there will be two signatures required on all accounts payable checks. See full Corrective Action Plan on district letterhead.

View Audit 24136

Finding 35227 (2022-003)

Material Weakness 2022

Southeastern Cusd #337

IL

Internal Control / Segregation of Duties Reporting

Condition: The District has one office personnel that is involved in the accounting function. Therefore, the District does not have an adequate segregation of duties over accounting transactions as the employee is responsible for initiating and recording transactions in the general ledger as well...

Condition: The District has one office personnel that is involved in the accounting function. Therefore, the District does not have an adequate segregation of duties over accounting transactions as the employee is responsible for initiating and recording transactions in the general ledger as well as performing reconciliations. There were 2 errors in calculating payroll benefits charged to the grant that were not discovered and corrected by District personnel. Plan: Due to the small size of the District, it is not practical to hire additional personnel solely for the purpose of achieving an ideal segregation of duties over the accounting function. The Superintendent and the Board of Education will review and closely monitor the accounting information on a regular basis. Anticipated Date of Completion: Ongoing Name of Contact Person: D. Todd Fox, Superintendent Management Response: We agree with the finding.

View Audit 30011

Finding 35226 (2022-001)

Significant Deficiency 2022

Be A Champion INC

TX

Significant Deficiency Internal Control / Segregation of Duties

Views of responsible officials and planned corrective action: The Organization agreed with the finding and implemented the recommended procedures.

View Audit 24609

Finding 35215 (2022-002)

Significant Deficiency 2022

Milwaukee Institute of Art and Design, Inc.

WI

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

Action Plan For the Year Ended May 31, 2022 Finding 2022-002 Section III ? Federal and State Awards Findings and Questioned Costs Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid clu...

Action Plan For the Year Ended May 31, 2022 Finding 2022-002 Section III ? Federal and State Awards Findings and Questioned Costs Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid cluster. Finding type: Noncompliance Criteria: The Institute is responsible for safeguarding sensitive data under the Gramm-Leach-Bliley Act, including performing a risk assessment that addresses three required areas noted in 16 CFR 314.4 (b). Statement of condition: A formal risk assessment is not documented which addresses required areas noted in 16 CFR 314.4 (b). Questioned costs: Questioned costs could not be determined. Context: The Institute has safeguards for each area identified within 16 CFR 314.4 (b) in place; however a formal risk assessment and documentation of the relevant safeguards implemented by the Institute to address the risks is not documented. Cause: There is no formal risk assessment documented. Effect: The Institute has no verifiable evidence of the risk assessment performed and the related safeguard for each risk identified. Recommendation: We recommend management review 16 CFR 314.4 (b) to perform a risk assessment that addresses the three required areas, which are (1) employee training and management; (2) information systems, including network and software design, as well as information processing, storage, transmission and disposal; and (3) detecting, preventing and responding to attacks, intrusions, or other systems failures. Management?s Response: Management agrees with the finding. Corrective Action: MIAD will review 16 CFR 314.4 (b) and develop a written Information Security Plan (ISP) that outlines the procedures and practices to protect non-public personal information (NPI) and manage information security risks. MIAD will provide routinely scheduled training to all current and new employees on the importance of protecting NPI and the procedures they must follow, to ensure that employees are up-to-date with the latest information security best practices. MIAD will continue to conduct regular risk assessments to identify potential security vulnerabilities, both internal and external, to evaluate the effectiveness of the ISP. MIAD will develop a plan to investigate and respond to security incidents that may compromise NPI. If an incident occurs MIAD will follow the ISP to remedy the incident, and revise the ISP as needed. Matt Ogden Director of Technology 414.847.3223 mattogden@miad.edu February 14th 2023

View Audit 24280

Finding 35214 (2022-001)

Significant Deficiency 2022

Milwaukee Institute of Art and Design, Inc.

WI

Special Tests & Provisions Student Financial Aid Reporting

Corrective Action Plan For the Year Ended May 31, 2022 Finding 2022-001 Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid cluster. Finding type: Noncompliance and significant deficien...

Corrective Action Plan For the Year Ended May 31, 2022 Finding 2022-001 Assistance listing number(s), federal agency, and program name: 84.063, 84.007, 84.033, and 84.268; United States Department of Education (DOE), Student financial aid cluster. Finding type: Noncompliance and significant deficiency in internal control over compliance Statement of condition: Certain student records within the National Student Loan Data System (NSLDS) were identified with inaccurate data elements. Management's review of the enrollment reporting did not detect errors on certain student data elements. Context: Five students were identified with inaccurate data elements reported out of a total of 40 students tested. Cause: The preparer incorrectly input the student's status into NSLDS resulting in inaccuracies in significant Campus-Level and Program-Level enrollment data elements that ED considers high risk. The Institute?s internal control over compliance did not detect and correct the error. Effect: The Institute incorrectly reported certain Campus-Level and Program-Level records in NSLDS which is information that DOE considers high risk and the Institute?s internal controls over compliance did not detect and correct the errors. Recommendation: We recommend management review policies and procedures surrounding enrollment reporting submissions to ensure the accuracy of data elements reported to DOE. A review performed by an appropriate individual separate from the preparer prior to the submission of the enrollment reports to NSLDS may improve the accuracy of enrollment reporting. Status completed Corrective Action Management agrees with the finding. Through internal investigation, it was determined that the issue arose through National Student Clearinghouse (NSC), which reports the Institute?s data to NSLDS. Management will work with NSC to assure graduates are accurately reported as soon as possible within existing external systems. The changes to management?s enrollment reporting procedures will be added to the Institute?s NSC submissions procedure documentation. Contact Jean Weimer Registrar 414-847-3272 jeanweimer@miad.edu submitted 2/23/2023

View Audit 24280

Finding 35208 (2022-001)

Significant Deficiency 2022

Metropolitan Community College Area

NE

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

2022-001 Student Financial Aid Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the College reviews outstanding checks regularly to ensure funds are returned to the Department of Education before 240 days of the original disbursement attempt. Explanation of disagreement with audi...

2022-001 Student Financial Aid Cluster - Assistance Listing No. 84.268 Recommendation: We recommend the College reviews outstanding checks regularly to ensure funds are returned to the Department of Education before 240 days of the original disbursement attempt. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: MCC will implement a process to review outstanding checks on a timely basis which will allow time to contact student and reissue payment. If student can not be found, funds will be returned to the Department of Education either through COD or direct payment prior to the required 240 days. Name(s) of the contact person(s) responsible for corrective action: Lewis Hendrickson Planned completion date for corrective action plan: Prior to Fall 2023

View Audit 24381

Finding 35206 (2022-002)

None 2022

Iowa City Community School District

IA

Reporting Internal Control / Segregation of Duties

Corrective Actions Taken or Planned: During testing by RSM of the student records related to the Title I program, a record of a student's withdrawal from the District was not maintained. RSM provided this testing irregularity to the appropriate District staff and the District has adjusted its record...

Corrective Actions Taken or Planned: During testing by RSM of the student records related to the Title I program, a record of a student's withdrawal from the District was not maintained. RSM provided this testing irregularity to the appropriate District staff and the District has adjusted its recording for the 2022-2023 school year realted to include additional signoffs from parents/guardians or communications with other districts or programs. In addition, the District has added additional documentation steps within Infinite Campus, its student information system, to track those students entering or exiting these student support programs. These procedures will be continued for June 30, 2023 and future fiscal years. Leslie Finger, Chief Financial Officer is responsible for the corrective action plan.

View Audit 23981

Finding 35202 (2022-002)

Significant Deficiency 2022

Survivor Empowerment Center

IL

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

Finding No. 2022-002 ? Salaries and Benefits Not Supported by Proper Time and Effort Documentation Federal Program: Crime Victim Assistance Project No: 219001 and 216001 CFDA No: 16.575 Passed Through: Illinois Coalition Against Domestic Violence and Illinois Coalition Against Sexual Assault Federa...

Finding No. 2022-002 ? Salaries and Benefits Not Supported by Proper Time and Effort Documentation Federal Program: Crime Victim Assistance Project No: 219001 and 216001 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: ? Two employee?s timesheets did not reflect the correct allocation percentages determined by the Organization, and ? One employee did not have a time and effort certification submitted during the 4th quarter of 2022. Plan: The Survivor Empowerment Center, Inc. is currently in the process of training a new HR 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 February 10, 2023 ? the next payroll. Name of Contact Person: Susan Hicks, Assistant Director

View Audit 24593

Finding 35198 (2022-001)

None 2022

Perry Public Schools

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Cash Management

CORRECTIVE ACTION PLAN 2022-001 This finding is caused by the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. There was lack of consistency and communication between the Food Service Director and the Business Manager during the fiscal ...

CORRECTIVE ACTION PLAN 2022-001 This finding is caused by the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. There was lack of consistency and communication between the Food Service Director and the Business Manager during the fiscal year in relation to meal claims. The persons responsible for the corrective action are Janet Killingsworth, the food service director and Dr. Lori Haven, the superintendent. The anticipated completion date of the corrective action plan is before the end of the 2023 fiscal year. The plan for monitoring adherence is the food service director and finance director will work together to ensure that monthly meals served are being reconciled prior to any meal reimbursement requests are made.

View Audit 24032

Finding 35197 (2022-006)

Significant Deficiency 2022

Housing Authority of the City of Dodge City

KS

HUD Housing Programs Internal Control / Segregation of Duties

2022-006. SEMAP Supporting Documentation Corrective action planned: Training of our new Maintenance Director so he can do the four required quality control HQS inspections on our Voucher Program units. Contact person: Matt Brady, Executive Director. Anticipated completion date: He is trai...

2022-006. SEMAP Supporting Documentation Corrective action planned: Training of our new Maintenance Director so he can do the four required quality control HQS inspections on our Voucher Program units. Contact person: Matt Brady, Executive Director. Anticipated completion date: He is trained now and will complete the 4 required inspections this summer. They will all be completed no later than September 30, 2023.

View Audit 24020

Finding 35196 (2022-005)

Significant Deficiency 2022

Housing Authority of the City of Dodge City

KS

HUD Housing Programs Reporting Equipment & Real Property Management

2022-005. Significant Audit Adjustments Corrective action planned: At the end of every fiscal year from this point forward the Executive Director will make certain that our fee accountant has received all information sent to them. Contact person: Matt Brady, Executive Director. Anticipa...

2022-005. Significant Audit Adjustments Corrective action planned: At the end of every fiscal year from this point forward the Executive Director will make certain that our fee accountant has received all information sent to them. Contact person: Matt Brady, Executive Director. Anticipated completion date: September 30, 2023

View Audit 24020

Finding 35176 (2022-002)

Significant Deficiency 2022

Kildahl Park Pointe Cooperative

MN

Reporting Internal Control / Segregation of Duties

Housing and Urban Development Kildahl Park Pointe Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2022. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2022 The findings from the Dece...

Housing and Urban Development Kildahl Park Pointe Cooperative respectfully submits the following corrective action plan for the year ended December 31, 2022. Westberg Eischens, PLLP 2630 1st Street South P.O. Box 362 Willmar, MN 56201 Audit Period: December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Summary of audit results does not include findings and is not addressed. Finding 2022-002 Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 24582

Corrective Action Plans

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