Corrective Action Plans

Finding 514164 (2023-003)

Material Weakness 2023

CO

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County follow their internal procurement policy procedures and keep documentation of such procedures to ensure compliance with the federal procurement requirements. E...

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County follow their internal procurement policy procedures and keep documentation of such procedures to ensure compliance with the federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement new policies and procedures to ensure that all expenditures of American Rescue Plan (APRA) funds will follow the procurement guidelines outlined in the US Treasury rules and regulations as well as County procurement policies for any new ARPA contracts. Most all of the 2023 expenditures were part of contracts that were already in place when the 2022 findings came out in September 2023 so this could not be corrected. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: December 1, 2024

View Audit 332366

Finding 513823 (2023-005)

Significant Deficiency 2023

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a pr...

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement policy in accordance with UGG, will collaborate more closely with project partners of federal grants to ensure documentation requirements for the procurement process are adhered to and work to centralize grant documentation for all awards. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and centralization of grant documentation to be established by March 31, 2025.

View Audit 331804

Finding 513773 (2023-003)

Material Weakness 2023

Black Mesa Community School

AZ

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

2023-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and...

2023-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b) the School remained in compliance with federal requirements. Context: During our review of the school’s accounting records and internal controls, as well as through management inquiry, we noted the following:  For eight of 25 accounts payable transactions tested out of the 15.042 grant, the school did provide adequate documentation to support the allowability of the expenditure.  For twenty-five of 25 accounts payable expenditures tested out of the 15.046 grant, the school paid amounts to and on behalf of illegitimate board members, totaling $82,127.  For twenty-five of 25 payroll disbursements tested out of the 15.046 grant, the school paid board meeting stipends to illegitimate board members, totaling $9,750. Repeat Finding: No. Action planned in response to the finding: Management will evaluate its internal controls over records management to ensure that all accounts payable disbursements are properly supported, and School Board expenditures are only paid out to and on behalf of eligible individuals. Planned completion date for a corrective action plan: June 30, 2024 Name of the contact person responsible for corrective action: Marie Rose, Principal

View Audit 331731 Questioned Costs: $1

Finding 513772 (2023-001)

Significant Deficiency 2023

Ali Forney Center, Inc.

NY

Matching / Level of Effort / Earmarking

Management acknowledges the finding and has initiated steps to address the identified issues. During CY2024, management made a strategic decision to outsource the entire fiscal operations to industry lead BTQ Financial services. The cooperation with the new fiscal vendor will increase on compliance ...

Management acknowledges the finding and has initiated steps to address the identified issues. During CY2024, management made a strategic decision to outsource the entire fiscal operations to industry lead BTQ Financial services. The cooperation with the new fiscal vendor will increase on compliance and timely financials reports that overall ensure timely audit completion and submission of DCF report.

View Audit 331728

Finding 513727 (2023-001)

Significant Deficiency 2023

People Acting in Community Endeavors, Inc.

MA

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Reporting

Management strives to operate within a model of continuous improvement and will review and improve processes appropriately to provide for timely reporting on a go-forward basis.

View Audit 331629

Finding 513711 (2023-001)

None 2023

Centre Care, Inc.

PA

Procurement, Suspension & Debarment Student Financial Aid Reporting

a. Comments on the Findings and Each Recommendation Due the ongoing impact of the COVID 19 pandemic, the Organization and CHR Consulting Services, Inc. (“CHR”), the entity responsible for maintaining the books and records of the Organization, experienced staffing shortages due to retirements and med...

a. Comments on the Findings and Each Recommendation Due the ongoing impact of the COVID 19 pandemic, the Organization and CHR Consulting Services, Inc. (“CHR”), the entity responsible for maintaining the books and records of the Organization, experienced staffing shortages due to retirements and medical leave. In addition, as a result of the ongoing impact of the COVID 19 pandemic, the Organization continued to experience noncompliance with certain debt covenants in 2023 and first half of 2024. In addition, the Organization had several vendor or liabilities, including the Pennsylvania bed tax liability that required resolution prior to the issuance of the audited financial statements. b. Action(s) Taken or Planned on the Finding The Organization and CHR have been able to recruit additional staff and CHR has added additional supervisory personnel to oversee the financial reporting and audit process. In an effort to improve communications with the Grantor, in August 2023, the Organization began providing monthly financial and operational information. In addition, monthly calls were implemented with the representatives of the Grantor, discussing key operational and performance measures. While key issues were identified and discussed with the Grantor, the Grantor has not been able to provide waivers for such noncompliance with covenant requirements. As noted in Note 2 the audited financial statements, the financial performance of the Organization has improved, allowing the Organization to enter into long-term payment plans for the resolution of the key liabilities of the Organization. It is anticipated that the audit for 2024 and related forms will be issued within the allowable time period in the loan agreements.

View Audit 331617

Finding 513710 (2023-005)

None 2023

Dodge County, Georgia

GA

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Management will produce written procurement policies and procedures for federal awards and subawards in compliance with the Uniform Guidance and Single Audit Standards.

View Audit 331614

Finding 513453 (2023-004)

None 2023

Community Development Partnership

MA

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

We are in process of submitting the required operating budget and self-certification letter to the USDA. Anticipated Completion Date- 12/31/2024 Completed.Responsible Contact Person-Kathleen Boyce, CFAO

View Audit 331288

Finding 513424 (2023-005)

Material Weakness 2023

Hinds County School District

MS

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303

Corrective Action: The district will ensure that all supporting documents will be stored electronically first and stored physically as a secondary option. Each department will be responsible for maintaining a copy of all supporting documentation. All checks and contracts will be included in the proc...

Corrective Action: The district will ensure that all supporting documents will be stored electronically first and stored physically as a secondary option. Each department will be responsible for maintaining a copy of all supporting documentation. All checks and contracts will be included in the procurement packets for all expenditure. We are currently implementing this process and strengthening internal controls. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Corrective Action Start Date: October 31, 2024

View Audit 331265

Finding 513420 (2023-003)

Material Weakness 2023

Hinds County School District

MS

Questioned Costs Eligibility Material Weakness § 200.302 § 200.303

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows t...

Finding 2023-003 Corrective Action: Before any expenditure is obligated, all revisions/amendments will be approved in MCAPS first. The business Manager, Federal Programs Director, and Superintendent will ensure MDE's approval is tangible before any obligations. We will implement a tool that allows this process to be measured daily. Responsible Parties: Avery Johnson, Business Manager Robert Sanders, Superintendent Tiffany Lanier, Federal Programs Director Corrective Action Start Date: October 31, 2024

View Audit 331265 Questioned Costs: $1

Finding 513385 (2023-002)

None 2023

Stoneboro Development Corporation 033-11048

PA

Procurement, Suspension & Debarment HUD Housing Programs Reporting § 200.512

Stoneboro Development Corporation Stoneboro, Pennsylvania November 18, 2024 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the f...

Stoneboro Development Corporation Stoneboro, Pennsylvania November 18, 2024 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended June 30, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2023-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management and the board of directors work to improve occupancy and submit special claims requests to HUD for vacant units to improve cash flow to ensure timely payment of the mortgage payments and escrow deposits. Action Taken: We agree with Finding 2023-001 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company is increasing advertising to fill vacancies and submitting special claims requests to improve the cash flow. Additionally, the new management company is working with the lender to make additional mortgage payments and escrow deposits as cash flow permits. Finding 2023-002: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend the board of directors and management ensure that the audit and data collection forms are completed timely and the data collection form and required reported package are submitted electronically to the FAC each fiscal year going forward. Action Taken: We agree with Finding 2023-002 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure the data collection forms are submitted electronically to the FAC each fiscal year. Finding 2023-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend the board of directors and management ensure that the annual financial reports to HUD are submitted by the required due dates. Action Taken: We agree with Finding 2023-003 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure the annual financial reports to HUD are submitted once the audits are back on track with the scheduled due dates. Finding 2023-004: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management and the board of directors work to improve occupancy and submit special claims requests to HUD for vacant units to improve cash flow to ensure timely monthly deposits to the replacement reserve account are made as required. Action Taken: We agree with Finding 2023-004 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company is increasing advertising to fill vacancies and submitting special claims requests to improve the cash flow. Finding 2023-005: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management ensure supporting documentation is maintained for all disbursements from project operations. Action Taken: We agree with Finding 2023-005 and the recommendation described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure supporting documentation is maintained for all disbursements from project operations. Finding 2023-006: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management ensure supporting documentation is maintained for all cash receipts of the project. Action Taken: We agree with Finding 2023-006 and the recommendation described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure supporting documentation is maintained for all cash receipts of the project. If HUD has questions regarding this corrective action plan, please call (412) 246-9213. Sincerely yours, Trisha Jester Director of Multifamily Housing Arbors Management, Inc. Managing Agent

View Audit 331232

Finding 513384 (2023-001)

None 2023

Stoneboro Development Corporation 033-11048

PA

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

Stoneboro Development Corporation Stoneboro, Pennsylvania November 18, 2024 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the f...

Stoneboro Development Corporation Stoneboro, Pennsylvania November 18, 2024 U.S. Department of Housing and Urban Development City Crescent Building 10 South Howard Street Baltimore, Maryland 21201-2505 Stoneboro Development Corporation respectfully submits the following Corrective Action Plan for the year ended June 30, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended June 30, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding 2023-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management and the board of directors work to improve occupancy and submit special claims requests to HUD for vacant units to improve cash flow to ensure timely payment of the mortgage payments and escrow deposits. Action Taken: We agree with Finding 2023-001 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company is increasing advertising to fill vacancies and submitting special claims requests to improve the cash flow. Additionally, the new management company is working with the lender to make additional mortgage payments and escrow deposits as cash flow permits. Finding 2023-002: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend the board of directors and management ensure that the audit and data collection forms are completed timely and the data collection form and required reported package are submitted electronically to the FAC each fiscal year going forward. Action Taken: We agree with Finding 2023-002 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure the data collection forms are submitted electronically to the FAC each fiscal year. Finding 2023-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend the board of directors and management ensure that the annual financial reports to HUD are submitted by the required due dates. Action Taken: We agree with Finding 2023-003 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure the annual financial reports to HUD are submitted once the audits are back on track with the scheduled due dates. Finding 2023-004: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management and the board of directors work to improve occupancy and submit special claims requests to HUD for vacant units to improve cash flow to ensure timely monthly deposits to the replacement reserve account are made as required. Action Taken: We agree with Finding 2023-004 described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company is increasing advertising to fill vacancies and submitting special claims requests to improve the cash flow. Finding 2023-005: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management ensure supporting documentation is maintained for all disbursements from project operations. Action Taken: We agree with Finding 2023-005 and the recommendation described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure supporting documentation is maintained for all disbursements from project operations. Finding 2023-006: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Market Interest Rate, Assistance Listing #14.155 Recommendation: We recommend that management ensure supporting documentation is maintained for all cash receipts of the project. Action Taken: We agree with Finding 2023-006 and the recommendation described in the accompanying schedule of findings and questioned costs. Effective June 1, 2023, the board of directors contracted with a new management company. The new management company will ensure supporting documentation is maintained for all cash receipts of the project. If HUD has questions regarding this corrective action plan, please call (412) 246-9213. Sincerely yours, Trisha Jester Director of Multifamily Housing Arbors Management, Inc. Managing Agent

View Audit 331232 Questioned Costs: $1

Finding 513379 (2023-003)

Material Weakness 2023

New Jersey City University

NJ

Student Financial Aid Subrecipient Monitoring Cash Management

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls ...

The University agrees with the finding. The University has had a significant amount of staff turnover and reorganization in FY 2023 in the financial aid office. The Interim Director of Financial Aid is collaborating with the controller’s office to make sure that the University has internal controls in place over Federal programs to assure that the Pell reporting requirements are executed in compliance with Federal statutes, regulation and terms and conditions of the federal award. The University is investing in making sure that the Financial Aid Office is staffed and create policy and procedure that assure that we improve internal controls on the Pell process.

View Audit 331221

Finding 513249 (2023-003)

Material Weakness 2023

County of Dauphin

PA

Matching / Level of Effort / Earmarking Reporting

Finding 2023-003 Matching, Level of Effort, Earmarking, Program Income and Reporting Aging Cluster (ALN 93.044/93.045/93.053) Corrective Action: Management is in agreement with the finding. Management will ensure the necessary reports are filed with the granting agency in a timely fashion and amoun...

Finding 2023-003 Matching, Level of Effort, Earmarking, Program Income and Reporting Aging Cluster (ALN 93.044/93.045/93.053) Corrective Action: Management is in agreement with the finding. Management will ensure the necessary reports are filed with the granting agency in a timely fashion and amounts reported are accurate. Management anticipates corrective action to be in place by 01/01/2025. Responsible party: Mary Bateman, Controller.

View Audit 331199

Finding 513233 (2023-001)

Material Weakness 2023

Aha Punana Leo, Inc.

HI

Reporting Matching / Level of Effort / Earmarking

ʻAha Pūnana Leo is reviewing grants and awards from federal and nonfederal sources and identifies and tracks all federal funds. We will strengthen our internal controls over reviewing the accuracy and completeness of the SEFA for financial reporting purposes. We have since implemented an additional ...

ʻAha Pūnana Leo is reviewing grants and awards from federal and nonfederal sources and identifies and tracks all federal funds. We will strengthen our internal controls over reviewing the accuracy and completeness of the SEFA for financial reporting purposes. We have since implemented an additional review step in the grant set-up process to specifically address the proper classification of revenue for each new funding source.

View Audit 331177

Finding 513084 (2023-003)

Material Weakness 2023

Allen County

IN

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

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Summary of Finding: The County submitted the four required quarterly P&E reports and the annual Recovery Plan Performance Report during the audit period; however, a single employee prepared and submitted each report without a review or oversight process in place to prevent, or detect and correct, errors. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-003, the Chief of Staff to the Board of Commissioners will have the Controller to the Board of Commissioners review the P&E Reports and the Recovery Plan Performance Report prior to being electronically submitted to the Department of Treasury via its State and Local Fiscal Recovery Funds portal. If errors are discovered by the Controller, the Chief of Staff will correct the electronic entry prior to submission. Anticipated Completion Date: This CAP will be completed by October 31, 2024, the deadline for submitting the third quarter 2024 P&E Report.

View Audit 331014

Finding 513083 (2023-002)

Material Weakness 2023

Allen County

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management § 200.303

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County,...

FINDING 2023-002 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Federal Agency: Department of the Treasury Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purposes of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. The Department of Health was required to submit data through the online portal, National Electronic Disease Surveillance System (NEDSS) Base System (NBS), monthly beginning in October 2022. The submitted data included program specific metrics relating to patient case management of certified Elevated Blood Lead Levels (EBLLs). The Department of Health was also required to ensure environmental investigation activities completed, including risk assessments and environmental inspections, were documented in the Indiana I-LEAD database monthly by a licensed Lead Risk Assessor. Environmental investigation activities performed by the Department of Health were documented in the Indiana I-LEAD database by a licensed Lead Risk Assessor who was an employee of the Department of Health. Similarly, case management activities performed were documented in the NEDSS Base System (NBS). Once activities were documented in the I-LEAD and NBS systems, the activities were further documented in a spreadsheet by the Lead Risk Assessor (for I-LEAD activities) and the Case Management Coordinator (for NBS activities). The spreadsheet was reviewed by the Director of the Environmental Services Division and the Finance Director monthly. The Finance Director then used the spreadsheet to prepare the monthly reimbursement requests and sent the monthly reimbursement requests to the Indiana Department of Health. We determined through inquiry with the Director of the Environmental Services Division and the Finance Director that while there was a review of the monthly spreadsheet, there was not a second review of the spreadsheet back to the activities reported in I-LEAD and NBS for accuracy. Additionally, the Finance Director prepared and submitted the reimbursement requests to the State without a second review or oversight process in place to prevent, or detect and correct, errors prior to submission. The lack of internal controls was a systemic issue throughout the audit period. Recommendation We recommend that management of the Health Department design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: We were unaware of a requirement for a secondary review of each document/spreadsheet/database input/task that was conducted prior to submission to the Finance Director (defining the completed cases for which to invoice the State), and a requirement for a secondary review of the invoice/billing documents prior to submission to the State. We were informed that the State review process (as was described to SBOA staff) was the check and balance needed which ensured we had appropriately entered the data into the required database(s) and that we had then subsequently billed for those very same appropriately completed and entered cases. However, when we were informed of the outcomes of the SBOA audit and the subsequent need for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP -- as we do now understand that despite the inaccurate instructions we were given, we did not appropriately do what the law requires locally relative to ensuring accurate completion of duties under grant contracts before submission for reimbursement. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a primary and secondary staff member will be identified for each step of the database entry (as an example, and this will follow whatever the duties are defined by the grant and a primary responsible staff member will be defined per grant duty needs) as well as for the invoicing/billing documentation process. The primary staff member(s) will be responsible for doing what is defined in the grant contract (a duty, task, data entry, invoice creation, etc.) and the secondary staff member will be responsible for verifying the work of the primary staff member(s). (In some cases, when there are diverse duties and more than one primary staff member is needed to do the duties of the grant, there may be several primary staff members assigned to various duties as needed) If disparities are encountered (such as errors or omissions) in any step related to the above duties, they will first be reported the primary staff member for likely easy correction or resolution. If a pattern exists or repetitive errors are identified through the review and verification process, the secondary reviewer will report the issue(s) to the Department Administrator to make a determination as to whether the primary staff member’s duties are transferred to another staff member, or if the person is simply re-educated. The goal will be to ensure there is an appropriate check and balance step (as well as remediation/correction step if warranted) in place for all tasks and documentation completion as it relates to grant-funded duties and invoicing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024.

View Audit 331014

Finding 513052 (2023-007)

Significant Deficiency 2023

Community Christian College

CA

Student Financial Aid Reporting Significant Deficiency

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan Corrective action plan to ensure enrollment reporting is completed timely and accurately I. The admissions team sends a list of all enrolled students 2. Financial aid will manually enter the student's informat...

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan Corrective action plan to ensure enrollment reporting is completed timely and accurately I. The admissions team sends a list of all enrolled students 2. Financial aid will manually enter the student's information into campus IVY 3. Campus IVY updates the student's status in NSLDS every 30 days. 4. If a student withdraws from Community Christian College, financial aid will manually update the student status into campus IVY 5. NSLDS is updated upon completion of the withdrawal This process will ensure that Community Christian College updates enrollment statuses for every student timely

View Audit 330954

Finding 513051 (2023-006)

Significant Deficiency 2023

Community Christian College

CA

Student Financial Aid Special Tests & Provisions Reporting

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The following is the procedure that the College will be implementing to ensure that student withdrawal calculations are performed accurately and returned within 30 days: I. The registrar will send a list to f...

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The following is the procedure that the College will be implementing to ensure that student withdrawal calculations are performed accurately and returned within 30 days: I. The registrar will send a list to financial aid of all students that have dropped by end of day every Thursday of each week. The list will include date of determination (DOD) and last date of attendance (LOA) of each student b. DOD wiII be within 14 days of student LOA 2. Upon receipt of the list financial aid will complete the following for each student: a. Gather student's current ledger card b. Gather student's current Transcript c. Complete a cover sheet which indicated the current loan period of the student. d. Financial aid will send over items to yd patty processor in order for R2t4 calculation to be completed (Campus IVY) no later than Wednesday of the following week by end of business day. 3. Campus IVY will complete the R2T4 3-5 business days upon receipt and conduct the following: a. If a refund is required- campus IVY will schedule the refund, update student account and send to school. b. School (student accounts) will review the refund, update student account and monies will be placed in the operations account and sent back to GS. c. If a refund is not required based on the R2T4 results, Campus IVY will notate the student account. This corrective action plan will allow Community Christian College to complete the drop process for each student within 30 days from LOA.

View Audit 330954

Finding 513049 (2023-004)

Significant Deficiency 2023

Community Christian College

CA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The following is the procedure that the College will be implemented to ensure that student withdnrn al calculations are performed accurately and returned within 30 days: I. The registrar will send a list to fi...

Management's Response: We concur. View of Responsible Officials and Corrective Action Plan The following is the procedure that the College will be implemented to ensure that student withdnrn al calculations are performed accurately and returned within 30 days: I. The registrar will send a list to financial aid of all students that have dropped by end of day every Thursday of each week. a. The list will include date of determination (DOD) and last date of attendance (LOA) of each student b. DOD will be within 14 days of student LOA 2. Upon receipt of the list financial aid will complete the following for each student: a. Gather student's current ledger card b. Gather student's current Transcript c. Complete a cover sheet which indicated the current loan period of the student. d. Financial aid will send over items to 3rd party processor in order for R2t4 calculation to be completed (Campus IVY) no later than Wednesday of the following week by end of business day. 3. Campus IVY will complete the R2T4 3-5 business days upon receipt and conduct the following: a. If a refund is required- campus IVY will schedule the refund, update student account and send to school. b. School (student accounts) will review the refund, update student account and monies will be placed in the operations account and sent back to GS. c. If a refund is not required based on the R2T4 results, Campus IVY will notate the student account. This corrective action plan will allow Community Christian College to complete the drop process for each student within 30 days from LOA.

View Audit 330954

Finding 512958 (2023-001)

Material Weakness 2023

Housing Authority of Randolph County

WV

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Ex...

2023-001 – ALN 14.871 – Housing Voucher Cluster – Activities Allowed and Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024 2023-002 – Significant Deficiency in Internal Controls over Financial Reporting Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Person Responsible for Correction of Finding: Lisa Shaffer, Executive Director Anticipated Completion Date: December 31, 2024

View Audit 330764 Questioned Costs: $1

Finding 512930 (2023-001)

Material Weakness 2023

East Muskingum Local School District

OH

Matching / Level of Effort / Earmarking HUD Housing Programs

We will make sure we collect all appropriate documentation from the vendor to ensure that we are following the Davis-Bacon Act. We will require the contractor to pay prevailing wages and collect all the payroll records and enter into a contract for all work that will be completed. The contractor w...

We will make sure we collect all appropriate documentation from the vendor to ensure that we are following the Davis-Bacon Act. We will require the contractor to pay prevailing wages and collect all the payroll records and enter into a contract for all work that will be completed. The contractor we used did pay prevailing wages to his employees. We did not have the documentation to prove it timely or the signed contracts for the separate work. We will make sure we have all appropriate documentation and that it is explained before the contract is entered into.

View Audit 330692

Finding 512906 (2023-003)

Significant Deficiency 2023

Barry County, Missouri

MO

Reporting Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking

Due to changes in the federal reporting system, we had problems getting the information to upload to the federal reporting site. Reporting began well before the due date, and reaching out for assistance has proven unfruitful. In future reporting, every effort will be made to ensure timely submission...

Due to changes in the federal reporting system, we had problems getting the information to upload to the federal reporting site. Reporting began well before the due date, and reaching out for assistance has proven unfruitful. In future reporting, every effort will be made to ensure timely submissions.

View Audit 330670

Finding 512901 (2023-005)

Significant Deficiency 2023

Scotland County Memorial Hospital District

MO

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

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...

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. • Lack of account reconciliation causing large numbers of year end entries. The accounting staff were not involved in Balance Sheet account reconciliation. These accounts are now being reconciled and monitored monthly. The GASB 87 rules were not adopted due to the staff not being trained. Upon our switch to WIPFLI as our new auditors, we have adopted GASB 87 (starting in FY 2023). In addition, we make the GASB 87 adjustments monthly. • 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 loosing 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. Segregation of duties We have a small staff. However, we have carefully been analyzing the duties and capabilities of each person. Then we have made changes to increase the segregation of duties to improve our internal controls. We improve internal controls with monthly goals. We will continue to both develop our staff, analyze segregation of duties and tighten our internal controls. We are very proud of our accomplishments. Access Internal Controls The previous administration did not have focused reviews of access to data. We have starting in FY 2024 created a team approach to reviewing job functions, access to information and the limits we need to place on the access. One of the findings has been that we had too many people with edit access to areas that were not essential to their job duties. We meet bi-monthly and review roles, data requirements and view only or edit capabilities. The process is arduous and slow, but we are steadily make progress. There have been revisions, surprises and accomplishment. Responsible Party: Meagan Weber, CEO, Carolyn Davies, CFO & Brent Peirick, COO Estimated Completion Date: 6/30/2026

View Audit 330652

Finding 512898 (2023-004)

Significant Deficiency 2023

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 (SF-SAC) by the due date of March 31, 2024. Response: The hospital has new administration, a new finance team and h...

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 (SF-SAC) by the due date of March 31, 2024. Response: The hospital has new administration, a new finance team and has implemented additional internal controls. The 2022 financial statement audit is complete and the 2022 single audit will be issued prior to 12/31/2024. The 2024 audit is currently in progress and anticipated to be issued prior to 12/31/2024. Responsible Party: Carolyn Davies, CFO Estimated Completion Date: 12/31/2024

View Audit 330652

Corrective Action Plans

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