Corrective Action Plans

Finding 520312 (2024-003)

Significant Deficiency 2024

CA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The Financial Aid department will continue to review and update the reporting procedures. The Director of Financial Aid will review the origination and posting of loans with staff and train them to ensure that dates are consistent and in compliance with Title IV regulations.

View Audit 340029

Finding 520305 (2024-002)

Significant Deficiency 2024

Chaffey Community College District

CA

Student Financial Aid Reporting Significant Deficiency

The departments involved in the enrollment reporting process are continuing to review and enhance the workflow in order to report accurately. Monthly submissions by Information Technology Systems (ITS) will be completed in a timely manner to allow for prompt communication of corrections that are req...

The departments involved in the enrollment reporting process are continuing to review and enhance the workflow in order to report accurately. Monthly submissions by Information Technology Systems (ITS) will be completed in a timely manner to allow for prompt communication of corrections that are required, which are communicated to Admissions and Records by the National Student Clearinghouse (NSCH). Admissions and Records will ensure that error reports provided by NSCH are returned to NSCH within 10 business days to allow for a timely submission to the National Student Loan Database (NSLDS). Staff in Admissions and Records has been specifically assigned to complete error reports to contribute to a prompt submission. The Admissions and Records department will collaborate and communicate with the Financial Aid department to identify students with error codes in NSLDS in an effort to correct them. The Admissions and Records and Financial Aid departments will work with the Internal Auditor to perform semiannual reviews of NSLDS data to ensure accuracy of student records.

View Audit 340029

Finding 520293 (2024-003)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the ...

Management's Response: The College will strengthen its policies and procedures surrounding payroll grant disbursements to ensure expenses are properly approved and allowable under the specific grant budget. Management will ensure that budgets are amended when changes in pay rates occur during the grant award periods. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520291 (2024-002)

Significant Deficiency 2024

T.a. Lawson State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. M...

Management's Response: The College will strengthen its policies and procedures surrounding non-payroll grant disbursements to ensure disbursements are approved, allowable, and calculations supported. Management will review budgets on a monthly basis to ensure expenses do not exceed the budget. Management will review indirect cost calculations to ensure they are calculated at the correct percentages. Management will review invoices three months past year end to ensure the proper accrual of expenses. Anticipated Completion Date: February 28, 2025

View Audit 340025 Questioned Costs: $1

Finding 520287 (2024-001)

Significant Deficiency 2024

Calvin University

MI

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree wit...

Condition: The University does not have controls in place for review of Return of Title IV calculation. Planned Corrective Action: All R2T4 calculations will be reviewed by a second individual within the Calvin Financial Aid Office. Calculations will not become final until both individuals agree with the specifics of each calculation. Contact person responsible for corrective action: James Koeman, Director of Financial Aid Anticipated Completion Date: Already completed as of the 24FA term.

View Audit 340021

Finding 520227 (2024-003)

Material Weakness 2024

Covington Community School Corporation

IN

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302 § 200.303 § 200.328

Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II and ESSER III amounts reported on the Year 3 report ($347,59...

Context: The School Corporation was required to submit two Annual Data Reports to the Indiana Department of Education (IDOE) during the audit period to meet federal reporting requirements for ESSER grant awards. We noted that the ESSER II and ESSER III amounts reported on the Year 3 report ($347,591 and $337,851 respectively) did not agree to the underlying expenditure records ($135,355 and $159,811 respectively). Additionally, we noted that the ESSER II amount reported on the Year 4 report ($233,093) did not agree to the underlying expenditure records ($267,310) of the School Corporation. Contact Person Responsible for Corrective Action: Vicki Jones Contact Phone Number: 765-793-4877 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Annual report data will be submitted with the requested information and will be verified with a sign-off by the Superintendent. Anticipated Completion Date: July 2025

View Audit 339860

Finding 520216 (2024-001)

Material Weakness 2024

Tri-County School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During sample testing of 60 students for eligibility, we noted 7 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper appl...

Finding 2024-001 – Child Nutrition Cluster – Eligibility Context: During sample testing of 60 students for eligibility, we noted 7 instances where there was no documented review by someone other than the individual making the eligibility determination. The lack of review was isolated to paper applications. Contact Person Responsible for Corrective Action: Mr. Patrick Culp Contact Phone Number: 219-279-2418 Views of Responsible Official: We concur with the finding. Of note, this is a new finding as we have never experienced this problem before. For this audit period, the Tri-County Food Service Director suffered a serious foot injury, requiring her to miss an extended period of time. When the accident with the Food Service Director occurred, one of the first actions the corporation took was to contact IDOE about our situation. The IDOE was aware how the review the process would look during that time. While the Food Service Director was recovering, student eligibility was not reviewed properly. Description of Corrective Action Plan: The Tri-County School Corporation food service director will complete all initial reviews of student eligibility. The initial review will be for both electronic and paper applications. Once the initial review is complete, the Tri-County central office secretary will complete a second review. The secretary works in a different building and does not have a role in eligibility determinations. Anticipated Completion Date: Our corrective action plan began in August 2024, upon the return of our food service director, and this is the plan moving forward.

View Audit 339770

Finding 520161 (2024-002)

Significant Deficiency 2024

Tri-City Healthcare District

CA

HUD Housing Programs Cash Management Reporting

Finding 2024-002: Reporting – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Corrective Action Planned: The District agrees with the findings and management has implemented a corrective action plan to ensure the required reports are filed timely. Starting Ja...

Finding 2024-002: Reporting – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Corrective Action Planned: The District agrees with the findings and management has implemented a corrective action plan to ensure the required reports are filed timely. Starting January 2024, all financial reports were filed on time. Person Responsible for Corrective Action: Anh Nguyen, Controller Anticipated Completion Date: June 30, 2025

View Audit 339746

Finding 520055 (2024-001)

Significant Deficiency 2024

Champaign-Urbana Mass Transit District

IL

Reporting Matching / Level of Effort / Earmarking § 200.303

We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN} per the grant agreements in the initial review of the SEFA. The improved procedures will provid...

We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN} per the grant agreements in the initial review of the SEFA. The improved procedures will provide the needed structure to fulfill management's responsibility to accurately report the grantor agency/ pass-through grantor, assistance listing number, federal program name and number, and expenditures. Identification of major programs, utilizing the guidelines in the Office of Management and Budget's (0MB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance} are the responsibility of the auditor.

View Audit 339560

Finding 520054 (2024-001)

None 2024

The Cleveland Institute of Art and Subsidaries

OH

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Management acknowledges that there was an error with one over award of subsidized loan on a student. Student was given $448 (gross) over the aggregate subsidized limit. The overage was sent back to the Direct lender. Since the student graduated, the $448 was covered by a grant. A survey of all stude...

Management acknowledges that there was an error with one over award of subsidized loan on a student. Student was given $448 (gross) over the aggregate subsidized limit. The overage was sent back to the Direct lender. Since the student graduated, the $448 was covered by a grant. A survey of all students was completed and no other students were discovered to have been over their aggregate subsidized limit. • A student’s aggregate subsidized amount on NSLDS from his FAFSA record was listed at $17,948, allowing only $5,052 in remaining to reach the $23,000 aggregate limit on subsidized loan. Student was given $5,500 when it should have been $5,052. The $448 should have been given as unsubsidized loan. Student had previous loans from another school. (Powerfaids will catch this error if all of the historic loans were processed within our database.) • The student ISIR record did have Comment code 258: “Based upon data provided by the National Student Loan Data System (NSLDS) and your grade level, we have determined that you may have received a total amount of undergraduate student loans that is close to or equal to the loan limits established for the federal loan programs. Therefore, your eligibility for additional student loans may be limited.“ • The Federal processor usually sends a post-screening after federal aid is disbursed with warnings of limits: 255, 256, 258. 260 ad 261. This would cause a C-code on the student record. We did not receive a subsequent ISIR record on said student. Corrective Action Plan: Include in the Quality Assurance rules one for the ISIR codes associated with NSLDS overawarding of loans whether it be annual limits or aggregate limits. We will monitor these codes regularly during packaging season and subsequent to loan disbursing.

View Audit 339558

Finding 520046 (2024-001)

Significant Deficiency 2024

Transylvania University

KY

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

January 16, 2025 U.S. Department of Education 400 Maryland Ave SW Washington, DC 20212 Transylvania University respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Blue & Company, LLC 250 West Main Str...

January 16, 2025 U.S. Department of Education 400 Maryland Ave SW Washington, DC 20212 Transylvania University respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: Blue & Company, LLC 250 West Main Street, Suite 2900 Lexington, Kentucky 40507 The findings from the schedule of findings and questioned costs (the Schedule) for the year ended June 30, 2024 are discussed below and are numbered consistently with the numbers assigned in the Schedule. Identifying Number: 2024-001 Finding: Enrollment Reporting. The enrollment status for students who completed their graduation requirements in May 2024 was incorrect for more than 30 days. Corrective Actions Taken or Planned: This issue occurred because enrollment and degree verify files sent to the National Student Clearinghouse (NSC) at the end of a term were processed in a particular order and student enrollment data overwrote student graduated status data. To correct the impacted students, the university registrar requested that NSC reprocess the May 2024 degree verify file, which should have been processed last. To prevent a future recurrence, the registrar has modified the file upload schedule to reflect the correct order of processing and has updated office procedures to clarify that the degree verify file should be uploaded last, following the submission of all term enrollment data. In addition to altering the file submission schedule, the registrar will ensure the end-of-term enrollment file has been processed by the NSC before the Degree Verify file is submitted each term. January 16, 2025 U.S. Department of Education 400 Maryland Ave SW Washington, DC 20212 Estimated Completion Date: November 11, 2024 Responsible Personnel: Michelle Robinson, Registrar If you have any questions or would like any additional information regarding these matters, please let us know and we will be happy to provide. Sincerely, Lisa Custardo, CPA Chief Financial Officer

View Audit 339546

Finding 520004 (2024-002)

Material Weakness 2024

Sandusky Metropolitan Housing Authority

OH

HUD Housing Programs Material Weakness Matching / Level of Effort / Earmarking § 200.303

The Housing Choice Voucher Program administrator will review the HQS Inspection report upon receiving to ensure all units are following Federal requirements.

View Audit 339440

Finding 519860 (2024-001)

Significant Deficiency 2024

Salem State University

MA

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Finding number: 2024-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster AL #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: The R2T4 calculations were done in a timely manner. These errors were due to human error and is considered isolated in...

Finding number: 2024-001 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster AL #: 84.063 and 84.268 Award year: 2024 Corrective Action Plan: The R2T4 calculations were done in a timely manner. These errors were due to human error and is considered isolated incidents. The Financial Aid office has taken great steps over the years and improved the processes for identifying and processing R2T4 calculations in a timely manner. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented as of October 2024. Contact Person Scott Jewell, Director of Financial Aid

View Audit 339156 Questioned Costs: $1

Finding 519832 (2024-001)

Significant Deficiency 2024

St. John Fisher College and Subsidiaries

NY

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The University recognizes the importance of complying with all federal requirements. In this case out of the sample of students one student was reported late to NSLDS. During the processing of a student's academic status, there was a unique situation where the student's record remained active in our...

The University recognizes the importance of complying with all federal requirements. In this case out of the sample of students one student was reported late to NSLDS. During the processing of a student's academic status, there was a unique situation where the student's record remained active in our system due to the presence of an incomplete grade. In this case, because the incomplete grade delayed the finalization of the student’s academic status, the dismissal was not reported to NSLDS within the typical timeframe. Once the incomplete was resolved and the final status was updated, the necessary information was reported to NSLDS. Measures will be put in place to ensure all changes are processed timely, additional measures are as follows.  Adding the following language to the Graduate catalog, consistent with the Undergraduate catalog: Students with one or more Incomplete grades at the end of the term have an academic standing of On Hold until the Incomplete grade(s) is resolved. When all Incomplete grades are converted to letter grades, the term and cumulative GPA are recalculated and academic standing is set according to the Standards of Academic Progress.  Before any dismissal decision is finalized, the Registrar’s Office verifies that all incomplete grades for the student have been resolved and that final grades are recorded in the system. This verification ensures that no student is dismissed prematurely or inaccurately in the academic records. Implement a workflow process as a double check in the student information system that monitors the status of incomplete grades for students who are dismissed, the system will generate alerts to the Registrar’s office when an incomplete grade is pending resolution in conjunction with dismissal.  Implementing controls to ensure accurate grading in conjunction with dismissals in the Student Information System will enable precise reporting to NSC/NSLDS

View Audit 339019

Finding 519823 (2024-004)

Material Weakness 2024

Cots and Affiliates

MI

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.303

Condition: The Organization lacked sufficient controls to ensure consistent reviews/approvals of monthly reimbursement requests and tenant rent calculations throughout the year. Planned Corrective Action: - The Rent Analyst will complete the rent calculations and sign off. - The Director of Account...

Condition: The Organization lacked sufficient controls to ensure consistent reviews/approvals of monthly reimbursement requests and tenant rent calculations throughout the year. Planned Corrective Action: - The Rent Analyst will complete the rent calculations and sign off. - The Director of Accounting will review and approve the checklist in writing. Contact person responsible for corrective action: The Director of Accounting will oversee all rent calculations. Anticipated Completion Date: Effective 01-13-2025.

View Audit 339017

Finding 519817 (2024-001)

Material Weakness 2024

Brownsburg Community School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2024-001 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23,...

FINDING 2024-001 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the eligibility compliance requirement. Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal review control in place. There is no documented, secondary review for the applications entered in the food service software which determines eligibility. Additionally, there was no documented review by School Corporation personnel of the Income Eligibility Guidelines used by the food service software which are updated on annual basis. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will formally sign off on the Mosaic income guidelines annually prior to each school year. Responsible Party and Timeline for Completion: Shane Hacker, Assistant Superintendent of Operations; Corey Ebert, Director of Finance; Jordan Ryan, Director of Nutrition Services Anticipated Completion Date: February 1, 2025

View Audit 339014

Finding 519811 (2024-002)

Significant Deficiency 2024

Bevill State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfeder...

Information on the Federal Program: U.S. Department of Education, Trio Cluster and Appalachian Regional Commission (ARC), Appalachian Area Development Assistance Listing No. 23.002 Criteria: 2 CFR 200 Subpart E establishes cost principles to apply in determining costs under federal awards. Nonfederal entities are also required to establish controls over the disbursement process to ensure compliance with allowable cost requirements. Condition: We selected a Trio sample of 25 payroll charges, containing 56 employee paychecks. Of those 56, five employee's approved pay was not properly documented. The employee had additional pay not on the approved Letter of Appointment (LOA) or the LOA reflected the use of restricted dollars, but the pay was charged to the grant. In addition, of those 56, five employees were charged to a grant that they were not budgeted for. We selected an ARC sample of 10 nonpayroll disbursements to test for controls. Of those 10, one disbursement of four scholarships was not properly documented as approved for payment. Management’s Response: The College will strengthen its policies and procedures surrounding the disbursement process. The College will document approvals on all payroll changes at the college and on the grant budgets. All scholarships will have prior written approval before scholarships will be applied. The College will also amend all grants when needed to properly reflect all job titles and expenditure items. Anticipated Completion Date: February 28, 2025

View Audit 339006 Questioned Costs: $1

Finding 519803 (2024-001)

None 2024

A.c. Ware Housing Development Fund Company, Inc.

NY

Special Tests & Provisions HUD Housing Programs Matching / Level of Effort / Earmarking

Corrective Action Plan (CAP) Name of auditee: A.C. Ware Housing Development Fund Company, Inc. TIN: 014-EE181 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: September 30, 2024 CAP prepared by: Andrea D. Mays President ADM Management Group, Inc. (716) 892-1799 Current Findings on...

Corrective Action Plan (CAP) Name of auditee: A.C. Ware Housing Development Fund Company, Inc. TIN: 014-EE181 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: September 30, 2024 CAP prepared by: Andrea D. Mays President ADM Management Group, Inc. (716) 892-1799 Current Findings on the Schedule of Findings and Questioned Costs and Recommendations (1) Finding 2024-001 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation. Please see below for action taken. (b) Action taken: Management is in the process of depositing funds, however, it currently does not have enough operating funds to deposit the underfunded amount of $16,785 into the reserve for replacements account. Management is in process of requesting a rent increase from HUD and will deposit funds as they become available.

View Audit 339005

Finding 519780 (2024-001)

Significant Deficiency 2024

North Central University

MN

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

There is no disagreement with the finding. The program length will be corrected for all students. In response to the findings from 2023, North Central corrected all program lengths within our Enterprise Resource Planning (ERP) system, Ellucian’s Colleague. Throughout the academic year, the Registrar...

There is no disagreement with the finding. The program length will be corrected for all students. In response to the findings from 2023, North Central corrected all program lengths within our Enterprise Resource Planning (ERP) system, Ellucian’s Colleague. Throughout the academic year, the Registrar’s Office and Financial Aid Department conducted thorough quality checks of the source data to ensure accuracy. Despite these efforts, unforeseen errors in enrollment data arose due to a data conversion issue between Colleague and the National Student Clearinghouse, which transmits information to the National Student Loan Data System (NSLDS). To address this, we will maintain our semesterly data confirmation process but will shift the primary focus of our reviews to the output data transmitted to NSLDS, ensuring data integrity at every stage of reporting.

View Audit 338943

Finding 519774 (2024-009)

Significant Deficiency 2024

Bishop State Community College

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

Management's Response: Management concurs with the above finding and all documentation for annual reports will be held and kept as required moving forward. This will be implemented with the 2025 annual report.

View Audit 338909

Finding 519772 (2024-007)

Material Weakness 2024

Bishop State Community College

AL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately ...

Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately and completed by June 2025.

View Audit 338909 Questioned Costs: $1

Finding 519769 (2024-012)

Significant Deficiency 2024

Bishop State Community College

AL

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC spe...

Management's Response: Management concurs with the audit finding above. The Director of Admissions & Records has worked with the Audit Resource team at NSC to work through a process to ensure that unofficial withdrawals are accurately captured from Banner and reported in a timely manner. The NSC specialist helped the college set up an additional "subsequent of term" submission roughly 30 days after the end of the semester but prior to the first upload of the following semester. As a nonattendance taking institution, this timeframe will allow the college a chance to make withdrawal determinations for students who did not officially withdraw but stopped attending at some point in the semester and code them appropriately in Banner. This action has occurred, been tested and implemented as of January 2025.

View Audit 338909

Finding 519763 (2024-005)

Significant Deficiency 2024

Scotland County Memorial Hospital District

MO

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

Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to th...

Finding # 2024-005 Condition: The District did not meet its financial covenants required under the program during the year, and we, as the auditors, were unable to properly calculate the required financial covenants because of potential missing or misstated financial statement information due to the adverse opinion on the 2022 financial statements and related disclaimer of opinion included in our accompanying 2023 Independent Auditor's Report Response: The hospital has financial covenants including: Maintaining 35 days cash on hand. We are currently at 26 Days Cash on Hand. The hospital has been as low as 6 Days Cash on Hand. To increase our Cash on Hand, we have brought all Revenue Cycle efforts in house, trained new staff, formed cross functional teams with the clinical documentation staff, set goals and work weekly with our teams to gently resolve challenges and move forward. These efforts have rewarded the hospital with increased Days Cash on Hand and improved quality processes in Revenue Cycle. One covenant requires that we maintain strong internal controls. Since the new administration have begun, each month, new internal controls are being established throughout the hospital, Finance department, Materials Management and the Revenue Cycle. On covenant requires a positive bottom line. The hospital has been losing money primarily due to the change in administration, lack of routine processes, recruitment challenges, lack of accuracy in our accounting and revenue cycle. Throughout the hospital and RHC’s, improvement teams are working to both improve quality processes, reduce costs, establish a culture to allow recruitment and improve our bottom line. The hospital has been transparent with the agency and our Board of Directors throughout our change process. More work continues. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2026

View Audit 338885

Finding 519762 (2024-004)

Significant Deficiency 2024

Scotland County Memorial Hospital District

MO

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we ar...

Condition: The District did not meet its financial reporting obligations under the grant during the year. The District did not complete the 2022 audit and file the Data Collection Form (SFSAC) by the due date of March 31, 2024 Response: The financial statement audit for FY 2022 is complete and we are awaiting issuance of the single audit for FY 2022. We anticipate the single audit stand-alone report will be issued prior to the end of 2025. The 2022 Report on Internal Control Over Financial Reporting and On Compliance and Other Matters Based on an Audit of Financial Statements Performed In Accordance with Government Auditing Standards has not been issued. We are currently working with our grantors and lenders to determine the appropriate course of action for not having this report. The hospital’s plan is to maintain timely completion of the financial audits in future years. Responsible Party: Meagan Weber, CEO, Brent Peirick, COO, Carolyn Davies, CFO Estimated Completion Date: 12/31/2025

View Audit 338885

Finding 519745 (2024-001)

Material Weakness 2024

Independent School District 695

MN

Material Weakness Reporting Matching / Level of Effort / Earmarking

Material Journal Entires Were Proposed Actions Planned - The District has implemented a plan for additional internal controls to develop increased review and reconciliations prior to the beginning of the audit. The District has recently hired new...

Material Journal Entires Were Proposed Actions Planned - The District has implemented a plan for additional internal controls to develop increased review and reconciliations prior to the beginning of the audit. The District has recently hired new business office staff and has provided additional training for UFARS reporting and compliance. Additionally, the proposed FY24 entries have been thoroughly reviewed by accounting staff and are used proactively for current review and reconciliation. Official Responsible - Business Manager and Superintendent of Schools. Planned Completion Date - December 31, 2024 Disagreement with Finiding - None - ISD #695 Chisholm concurs with the finding. Plan to Monitor - The District is aware of the situation and will monitor, as it deems appropriate. Monitoring will include monthly reiew of accounts in each fund by both the business office staff and administrative levels.

View Audit 338862

Corrective Action Plans

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