Corrective Action Plans

Finding 563920 (2023-010)

Material Weakness 2023

Barclay College

KS

Reporting Student Financial Aid Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lee Anders, Vice Pr...

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563918 (2023-008)

Material Weakness 2023

Barclay College

KS

Questioned Costs Student Financial Aid Material Weakness

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Da...

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096 Questioned Costs: $1

Finding 563916 (2023-007)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Enrollment Reporting to NSLDS Planned Corrective Action: A process will be created to ensure enrollment is reported timely and accurately. Spot checks of NSLDS will be performed on enrollment status throughout the year. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for B...

Enrollment Reporting to NSLDS Planned Corrective Action: A process will be created to ensure enrollment is reported timely and accurately. Spot checks of NSLDS will be performed on enrollment status throughout the year. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563911 (2023-006)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Eligibility Material Weakness

ISIR Comment Resolution Planned Corrective Action: All ISIR comment codes will be resolved before disbursement of federal aid to students. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563906 (2023-005)

Material Weakness 2023

Barclay College

KS

Eligibility Student Financial Aid Material Weakness

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09...

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563841 (2023-004)

Significant Deficiency 2023

Global Fund to End Modern Slavery

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month p...

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month period of transition at the Fund, while maintaining that proper allocation process was followed up to the point of record keeping. The Fund understands the reasons for the missing timesheets and that these cases were unique and not indicative of the normal and prevalent internal control over the completion and approval of timesheets. The allocation of payroll for the months tested were based on the consistent and correct application of the payroll costs allocation methodology however in a limited number of cases the allocation spreadsheets weren’t properly saved. After announcement of dissolution, there was considerable staff turnover and rapid transition which created challenges and delays. We did maintain an effective control environment. This has been resolved. Management is saving allocation spreadsheets, and other required documentation as per policy on an ongoing basis.

View Audit 358064

Finding 563805 (2023-004)

Significant Deficiency 2023

Taylor Regional Hospital, Inc.

GA

Significant Deficiency Matching / Level of Effort / Earmarking

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2023. The findings from the March 31, 2023 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the ...

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2023. The findings from the March 31, 2023 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDINGS Significant Deficiency (2023-004) Recommendation: The Hospital should immediately fund the Reserve Account to the proper funding level required by the USDA loan. Planned Corrective Action: The hospital agrees with this finding. See 2023-002.

View Audit 358013

Finding 562173 (2023-012)

Material Weakness 2023

Libson Regional School District

NH

Questioned Costs Matching / Level of Effort / Earmarking

2023-012 Maintenance of Effort (Material Weakness) Management’s Response: Training has been more of a self-learned activity but we are trying to get these done. Working with the auditors helped the most to understand what these reports should look like. The hope is to have 25-26 MOE’s completed in ...

2023-012 Maintenance of Effort (Material Weakness) Management’s Response: Training has been more of a self-learned activity but we are trying to get these done. Working with the auditors helped the most to understand what these reports should look like. The hope is to have 25-26 MOE’s completed in the Fall of 2025. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date – 10/1/2025

View Audit 357779 Questioned Costs: $1

Finding 562170 (2023-011)

Material Weakness 2023

Libson Regional School District

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

2023-011 Excess Food Service Fund Balance (Material Weakness) Management’s Response: We completed and Excess Balance Use of Funds report and worked with the State to understand exactly the parameters of this/ The funds were spent down and we are working hard to make sure to stay under the three mon...

2023-011 Excess Food Service Fund Balance (Material Weakness) Management’s Response: We completed and Excess Balance Use of Funds report and worked with the State to understand exactly the parameters of this/ The funds were spent down and we are working hard to make sure to stay under the three months of expenses as worded in CFR Title 7, 210.14(b). Again management is trying to take on a bigger role as this monitoring was not considered prior to COVID. Fund Balances at year end averaged no more than $10,000. Name of Contact Person and Completion Date: Toni Butterfield Anticipated Completion Date - Immediately

View Audit 357779 Questioned Costs: $1

Finding 561808 (2023-005)

Significant Deficiency 2023

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2023-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2025.

View Audit 357478

Finding 561550 (2023-001)

Material Weakness 2023

Listening House of St. Paul, Inc.

MN

Procurement, Suspension & Debarment Equipment & Real Property Management Matching / Level of Effort / Earmarking

Recommendation – Management and the board should establish a process for regular review of its consolidated financial statements with its contracted accountant to ensure activity is recorded in accordance with GAAP. Auditee's comments – Management and its contracted accounting staff will mon...

Recommendation – Management and the board should establish a process for regular review of its consolidated financial statements with its contracted accountant to ensure activity is recorded in accordance with GAAP. Auditee's comments – Management and its contracted accounting staff will monitor financial reports and activities of Listening House to ensure proper recording. Name(s) and contact person(s) responsible for corrective action: Molly Jalma, Executive Director. Planned completion date for corrective action plan: Ongoing.

View Audit 357162

Finding 561273 (2023-003)

Material Weakness 2023

Knott County Fiscal Court

KY

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.306 § 200.318 § 200.329

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will ende...

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will endeavor to make sure the FEMA files are updated and complete after FEMA reimbursement.

View Audit 356900 Questioned Costs: $1

Finding 560978 (2023-005)

Significant Deficiency 2023

Heading Home

NM

Matching / Level of Effort / Earmarking

View of Responsible Official and Corrective Action Plan Heading Home management agrees with this finding and is currently developing controls to ensure compliance with all grant matching requirements. The new controls will address a thorough review of each grant agreement, documentation of matching ...

View of Responsible Official and Corrective Action Plan Heading Home management agrees with this finding and is currently developing controls to ensure compliance with all grant matching requirements. The new controls will address a thorough review of each grant agreement, documentation of matching funds contributed by the organization, including cash contributions, in-kind donations, and volunteer hours, and the method of tracking match progress by either spreadsheet and/or within the accounting system. An appropriate individual will be assigned the responsibility for monitoring compliance and the internal controls over matching compliance including document retention and recordkeeping. Management is confident the match would have been met, but did not maintain the documentation necessary to prove this. Management anticipates the corrective action plan will be fully implemented by July 1, 2025. The personnel responsible for overseeing implementation include Connie Chavez, Chief Executive Officer; Debbie Brickman, Chief Financial Officer; and Armando Sanchez, contract accountant team lead.

View Audit 356632

Finding 560844 (2023-005)

Significant Deficiency 2023

Beaufort Jasper Hampton Comprehensive Services, Inc.

SC

Cash Management Reporting Matching / Level of Effort / Earmarking

We concur with the auditor's findings. We submitted the annual financial report during the period expense reimbursement was received instead of submitting it for the budget periods that ended. We are developing and implementing a grant reporting calendar listing federal financial report (FFR) due da...

We concur with the auditor's findings. We submitted the annual financial report during the period expense reimbursement was received instead of submitting it for the budget periods that ended. We are developing and implementing a grant reporting calendar listing federal financial report (FFR) due dates for all federal grants. We will use the automated alerts from the grants management system to track and remind staff of upcoming reporting deadlines. Lastly, we will maintain audit-ready documentation of each FFR submission.

View Audit 356598

Finding 560795 (2023-001)

Material Weakness 2023

International Association of Forensic Nurses, Inc.

MD

Questioned Costs Internal Control / Segregation of Duties Material Weakness

Action Taken: Management has implemented the following measures to address the issue and prevent future occurrences: • Improved the segregation of duties between the approval, recording and the booking of all expense transactions. • Automated the uploads of credit card transactions directly into the...

Action Taken: Management has implemented the following measures to address the issue and prevent future occurrences: • Improved the segregation of duties between the approval, recording and the booking of all expense transactions. • Automated the uploads of credit card transactions directly into the accounting system to prevent any manual manipulation and reconciled the transactions to the statements. • Updated the Association policies around vendor management and allowable/non allowable operating expenses. • We terminated the employee prior to discovering the fraud.

View Audit 356575 Questioned Costs: $1

Finding 560655 (2023-011)

Material Weakness 2023

Shenandoah School Corporation

IN

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

FINDING 2023-011 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports, and two ESSER III reports, for a total of six reports. The annual data reports were compiled, prepared, a...

FINDING 2023-011 Finding Subject: Education Stabilization Fund - Reporting Summary of Finding: During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports, and two ESSER III reports, for a total of six reports. The annual data reports were compiled, prepared, and submitted by the Director of Curriculum without oversight by another individual. All six of the submitted reports were selected for testing. One of the reports, ESSER II, Year 2; was not supported by the School Corporation's records. The School Corporation had expenditures of $583,415 from the ESSER II grant which was not included in this report. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager and Director of Curriculum will review the annual data reports together before submittal. Anticipated Completion Date: September 30, 2024􀀃

View Audit 356534

Finding 560646 (2023-009)

Material Weakness 2023

Shenandoah School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification ...

FINDING 2023-009 Finding Subject: Child Nutrition Cluster – Non-Profit School Food Service Accounts Summary of Finding: Receipts for the grant were posted to the ledger by one individual without an oversight or review process in place to ensure the remitter, amount, fund, and receipt classification were accurate. Additionally, the same individual received the ACH notifications when monies from monthly meal reimbursements were credited to the School Corporation's bank account and performed the bank reconciliations. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Food Service Director and Business Manager hold a monthly financial meeting to review the food service finances. A report listing all receipts for the previous month to the food service fund will be reviewed at this meeting. This item will be added to the agenda. Anticipated Completion Date: March 31, 2024

View Audit 356534

Finding 560645 (2023-008)

Material Weakness 2023

Shenandoah School Corporation

IN

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

FINDING 2023-008 Finding Subject: Child Nutrition Cluster – Special Tests & Provisions - Verification Summary of Finding: One individual performs the verification process without documented review/oversight by a second employee not involved in this process. The lack of controls resulted in non-compl...

FINDING 2023-008 Finding Subject: Child Nutrition Cluster – Special Tests & Provisions - Verification Summary of Finding: One individual performs the verification process without documented review/oversight by a second employee not involved in this process. The lack of controls resulted in non-compliance in which the procedures performed at the School Corporation and the resulting supporting documentation provided were insufficient to verify the student's eligibility status of one of three students which were verified during the audit period. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The verification process will be performed by Pam Frost and reviewed by the Business Manager. Anticipated Completion Date: December 31, 2024

View Audit 356534

Finding 560640 (2023-007)

Material Weakness 2023

Shenandoah School Corporation

IN

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

FINDING 2023-007 Finding Subject: Child Nutrition Cluster - Reporting Summary of Finding: Monthly reimbursement claims for breakfast and lunch meals served are prepared and submitted without documented review or approval by a second individual not involved in the preparation of the reimbursement cla...

FINDING 2023-007 Finding Subject: Child Nutrition Cluster - Reporting Summary of Finding: Monthly reimbursement claims for breakfast and lunch meals served are prepared and submitted without documented review or approval by a second individual not involved in the preparation of the reimbursement claim. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will calculate the monthly claims to be submitted to the DOE/CNP and email this information to the Business Manager for review before submittal. Anticipated Completion Date: March 31, 2024

View Audit 356534

Finding 560633 (2023-005)

Material Weakness 2023

Shenandoah School Corporation

IN

School Nutrition Programs Eligibility Cash Management § 200.303

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not b...

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Eligibility Summary of Finding: The School Corporation stated that 100% of Free/Reduced lunch applications were reviewed during the audit period. However, testing of controls indicated that 100% of Free/Reduced lunch applications were not being reviewed by an individual other than the individual making the initial determination. As a result, three of forty sampled students received the incorrect eligibility status in the system software when compared to supporting documentation (Direct Certifications and/or income-based applications). Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently all income based applications for free/reduced lunch status are processed by Pam Frost and then reviewed by the Business Manager. Beginning in the 2024-2025 school year Direct Certification students will also be reviewed by the Business Manager. Anticipated Completion Date: August 31, 2024

View Audit 356534

Finding 560623 (2023-003)

Material Weakness 2023

Shenandoah School Corporation

IN

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

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the det...

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Activities Allowed or Unallowed Summary of Finding: The School Corporation did not have internal controls in place over payroll disbursements charged to the food service program. Payroll disbursements were paid without evidence that the detailed report of payroll disbursements was reviewed and approved by another person not involved in the original payroll process. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Currently the Business Manager and Food Service Director hold a monthly financial meeting to review the status of finances for the Food Service. A review of the payroll distribution reports for the previous month will be added to the agenda of this meeting. Anticipated Completion Date: March 31, 2024

View Audit 356534

Finding 559954 (2023-003)

Significant Deficiency 2023

Mental Health Association in Orange County, Inc.

NY

Special Tests & Provisions HUD Housing Programs Significant Deficiency

• Finding 2023-003 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: MHA uses the official HUD COC Rent Determinat...

• Finding 2023-003 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: MHA uses the official HUD COC Rent Determination worksheets, as well as an external vendor (Affordable Housing Network) to establish that reasonable rents are charged for comparable apartments. Worksheets are now updated annually and verified by the Director of Corporate Compliance. The Assistant Director of Housing and Care Coordination will notify all staff responsible for administering HUD programs of the changes and train those staff accordingly. The external contract was established in mid-2024, and is still being used. o Person Responsible: Director of Corporate Compliance. o Date of Completion: June 10, 2024.

View Audit 355894

Finding 559265 (2023-002)

Significant Deficiency 2023

Oklahoma City Innovation District, Inc.

OK

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.512

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays e...

Recommendation: We recommend that management implement processes to ensure timely completion and submission of the Single Audit report in future years. This could include setting internal deadlines, increasing oversight, and coordinating with the audit firm to identify and address potential delays earlier in the audit process. Action Taken: Management agrees with the finding and will take steps to improve the timeliness of the audit process. Anticipated completion date: June 30, 2025 Name of contact person and title: Jeffrey Seymour, President / CEO

View Audit 355490

Finding 559174 (2023-002)

Significant Deficiency 2023

Ocab Community Action Agency, INC

SC

Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions

Management is actively working on retaining and recruiting knowledgeable personnel in the finance and account department to enhance the department's effectiveness and efficiency. OCAB has established agreements with account professionals to improve the training and efficiency of staff in the fiscal...

Management is actively working on retaining and recruiting knowledgeable personnel in the finance and account department to enhance the department's effectiveness and efficiency. OCAB has established agreements with account professionals to improve the training and efficiency of staff in the fiscal office, focusing on areas such as financial compliance, daily fiscal responsibilities month end closing and budget analysis. OCAB as slso hired 2 fiscal personnel in this department. We believe significant progress has been made since the last reorting period. A wage and benefits was completed and utilized in the process. OCAB believes that the measures taken will ensure compliance with all department of Health & Human Services regulations.

View Audit 355410

Finding 559065 (2023-001)

None 2023

Illuminate Colorado

CO

Cash Management Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.305

In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and r...

In alignment with this audit finding, Illuminate Colorado has implemented processes to improve working capital and address cash flow challenges, including:  improved invoicing procedures to ensure timely submission of invoices to minimize time elapsed between submission of invoices to funders and reimbursement of those invoices, and  seeking increased working capital via a larger line of credit or other source (foundation, corporate, or individual donations) In addition, Illuminate Colorado is in process of developing a Standard Operating Procedure to ensure consistent identification of vendors utilized for direct Federal assistance programs in order to prioritize payment of those vendors with federal drawdown receipts. Standard Operating Procedure will include:  Process to identify vendors paid with federal funds  Process to monitor invoice timelines of vendors paid with federal funds  Process to prioritize payments of vendors paid with federal funds following federal drawdowns  Process for internal review of payment timelines

View Audit 355335

Corrective Action Plans

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