Corrective Action Plans

Finding 520902 (2024-011)

Material Weakness 2024

WV

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.430

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process ...

FINDING 2024-011 Name of Responsible Individual: Tyler Hosey, Senior Accountant Corrective Action: The University acknowledges that the records to substantiate the payroll costs were insufficient and lacking internal controls. Going forward the University plans to implement a strategic process to document time and effort associated with research and development cluster and it’s federal grants. All employees that work with the Challenger Learning Center will continue to have their hours worked documented in the Paycom payroll software. Payroll is processed on a biweekly basis, and therefore on biweekly basis the payroll costs from the Challenger Learning Center will be reimbursed to the University from the various Challenger Learning Center bank accounts. This will be done as a percentage of time worked for the NIH Grant, the NASA Grant, and the general Challenger Learning Center functions. Anticipated Completion Date: June 2025

View Audit 340797 Questioned Costs: $1

Finding 520890 (2024-001)

Significant Deficiency 2024

MacOupin County Public Health Department

IL

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

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a ...

Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" four (4) selections out of a sample size of forty (40) did not obtain proper proof of income prior to applying the sliding fee discount. In addition, four (4) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Antcipated Date of Completion: March 31, 2025. Name of Contact Person: Lori Sanson, CFO. Management's Response: Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHC Supervisors will obtain a monthly report of the clients that have not turned in proof of income in order to proactively reach out either by phone, email or mail and attempt to obtain the information.

View Audit 340762

Finding 520889 (2024-001)

Significant Deficiency 2024

Independence Place Cooperative of Willmar

MN

Questioned Costs Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 340755

Finding 520883 (2024-002)

Significant Deficiency 2024

Shawmet Homes, Inc.

MO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded...

Recommendation: The Organization should review of its operating and maintenance policies and procedures, as well as review by the individuals monitoring the operating and maintenance of the property, to ensure that the necessary documentation showing that resident problems or concerns were responded to in a timely manner is being completed. View of Responsible Officials and Corrective Actions: Shawmet Homes, Inc. has, and will continue to complete problems or concerns raised by tenants, and only failed to document timely completion within in our management system. The Organization has reviewed its staffing and implemented training, and periodic reviews of the work order system, to ensure that the documentation is being completed timely.

View Audit 340740

Finding 520877 (2024-002)

Material Weakness 2024

Vandalia Cusd 203

IL

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

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520867 (2024-003)

Material Weakness 2024

Vandalia Cusd 203

IL

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

Payroll disbursements will align to the approved salary schedule.

View Audit 340710

Finding 520865 (2024-004)

Significant Deficiency 2024

Linden-Kildare Consolidated Independent School District

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the audit...

Due to the transition of personnel within the payroll and business office during the year, the District did not properly account for amounts that were previously requested under the grant as well as expense reversals that occurred near year-end. The District will take the recommendation of the auditors and implement additional controls to monitor compliance with federal program guidelines.

View Audit 340692 Questioned Costs: $1

Finding 520854 (2024-001)

None 2024

Williams College

MA

Questioned Costs Student Financial Aid Reporting

Management agrees with the finding and in concurrence with the recommendations we have reviewed the federal verification definitions, and the importance of selecting the correct verification status in the COD system, with staff who participate in the federal verification process to ensure they under...

Management agrees with the finding and in concurrence with the recommendations we have reviewed the federal verification definitions, and the importance of selecting the correct verification status in the COD system, with staff who participate in the federal verification process to ensure they understand the federal definition of number of family members in college. Ongoing training will be provided and a senior member of our staff will audit the verification process moving forward. This corrective action plan has been implemented as of January 2025.

View Audit 340686

Finding 520849 (2024-001)

None 2024

Concordia College

MN

Subrecipient Monitoring Questioned Costs

Corrective Action Plan August 23, 2024 Finding 2024-001: Reporting Criteria: The Gramm-Leach-Bliley Act (Pub. L. No. 106-102) (GLBA) requires institutions to explain their information-sharing practices to their customers and to safeguard sensitive data (16 CFR 314). In 2021, the Federal Trade Commi...

Corrective Action Plan August 23, 2024 Finding 2024-001: Reporting Criteria: The Gramm-Leach-Bliley Act (Pub. L. No. 106-102) (GLBA) requires institutions to explain their information-sharing practices to their customers and to safeguard sensitive data (16 CFR 314). In 2021, the Federal Trade Commission issued final regulations that altered the current required elements of an information security program and added several new elements. Under the regulations, institutions are required to develop, implement, and maintain a comprehensive information security program that is written in one or more readily accessible parts. The written information security program for institutions must address all elements that apply. The elements for the information security programs set forth in this section 16 CFR 314.4 are high-level principles that set forth basic issues the programs must address, and do not prescribe how they will be addressed. Condition: The College does not have a written information security program that addresses all elements that apply. Cause: The College’s procedures and processes in place specific to GLBA did not have written documentation of all required elements. Effect: Failure to comply with the requirements of GLBA standards puts the College at risk of compromising consumer, nonpublic personal information. Corrective Action Planned: The College does have a written information security program but does not currently have it in the format recommended by the auditors. The College will update the documentation of all required elements, specific to GLBA, following the auditors template. Anticipated Completion Date: October 16th, 2024 Name(s) of Contact Person(s) Responsible for Corrective Action: Erik Ramstad Executive Director Information Technology

View Audit 340680

Finding 520842 (2024-001)

Material Weakness 2024

Simpson University

CO

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

Incorrect and Untimely Returns of Title IV Funds (R2T4) Calculations Planned Corrective Action: The University agrees with these findings. It was determined that these issues primarily resulted from a critical staff shortage in the Financial Aid Office during the audit period. This shortage signific...

Incorrect and Untimely Returns of Title IV Funds (R2T4) Calculations Planned Corrective Action: The University agrees with these findings. It was determined that these issues primarily resulted from a critical staff shortage in the Financial Aid Office during the audit period. This shortage significantly impacted our ability to complete R2T4 calculations accurately and withing the required timeframe. To address these findings, the institution will prioritize the recruitment and onboarding of additional qualified staff to alleviate workload challenges and support timely processing of R2T4s. Concurrently, we will provide comprehensive training to all financial aid staff, focusing on federal regulations, calculation methods, and deadlines. To reduce errors, we will establish a robust quality assurance process that includes a secondary review of all R2T4 calculations before finalization. Person Responsible for Corrective Action Plan: Shondra Dickson, Director of Financial Aid Anticipated Date of Completion: September 1, 2025

View Audit 340662

Finding 520834 (2024-007)

Significant Deficiency 2024

Alamance County, North Carolina

NC

Questioned Costs Cash Management Significant Deficiency

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and makin...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Correction for the questioned costs were completed when reporting September 2024’s 1571. Supervisor has reviewed with accounts payable staff the importance of reviewing all aspects of the payable and making sure that information is accurate. Going forward supervisor will send out notification when IRS mileage reimbursement rates change and accounts payable staff will ensure the payable has the correct IRS mileage reimbursement rate listed. Proposed Completion Date: Immediate and ongoing.

View Audit 340657 Questioned Costs: $1

Finding 520826 (2024-006)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accur...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accuracy of entered information to minimize human error. All training sessions will continue to emphasize these expectations. The supervisor will conduct targeted second-party reviews in response to these findings to ensure accuracy. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520823 (2024-005)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Based on the audit results, it has been determined that three (3) files lacked a copy of the Responsible Individuals List, a mandatory document for completing adoptions in the State of North Carolina. Mana...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Based on the audit results, it has been determined that three (3) files lacked a copy of the Responsible Individuals List, a mandatory document for completing adoptions in the State of North Carolina. Management acknowledges this finding however further shares that without this form, the Clerk's Office is unable to process adoptions. Copies of these documents are available in the legal file; however, these records are sealed post-adoption and cannot be accessed by our agency. Other supporting documents, such as the Pre-Placement Assessment, were also provided to the auditors on these cases showing where it was documented that this requirement was met and that the individual’s information was processed and approved. This issue has been identified in previous audits, prompting the implementation of checks and balances to ensure sufficient copies are maintained at our office for future audits. Our staff now utilizes a review tool and undergoes a sign-off process, with oversight from supervisors to verify the presence of all required documents before filing and storage. Furthermore, the Department of Social Services (ACDSS) has been conducting a comprehensive internal audit of 100% of adoption cases to assess file completeness and address any deficiencies identified.It is important to note that older cases audited may still exhibit such deficiencies due to historical inadequacies in record keeping practices. Moving forward, we remain committed to maintaining rigorous standards of record management to prevent recurrence of these issues and ensure compliance with adoption processing requirements in North Carolina. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520822 (2024-004)

Material Weakness 2024

Alamance County, North Carolina

NC

Material Weakness Internal Control / Segregation of Duties Questioned Costs

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accur...

Name of Contact Person: Candice Gobble, DSS Director Corrective Action/Management’s Response: Management acknowledges this finding, noting that the reviewed cases include work from an earlier period. Caseworkers will be reminded to ensure proper filing of all documents and to double-check the accuracy of entered information to minimize human error. All training sessions will continue to emphasize these expectations. The supervisor will conduct targeted second-party reviews in response to these findings to ensure accuracy. Proposed Completion Date: Immediate and ongoing.

View Audit 340657

Finding 520794 (2024-002)

Material Weakness 2024

Blue Mountain Community College District

OR

Special Tests & Provisions Questioned Costs Material Weakness

The issue related to the Common Origination and Disbursement (COD) disbursement files continued to be an issue with our old Student Information System (SIS), Anthology. As of July 1, 2024, the College has moved to a new SIS, FOCAL. In addition, we moved to a standalone financial aid system, PowerFai...

The issue related to the Common Origination and Disbursement (COD) disbursement files continued to be an issue with our old Student Information System (SIS), Anthology. As of July 1, 2024, the College has moved to a new SIS, FOCAL. In addition, we moved to a standalone financial aid system, PowerFaids, that integrates with FOCAL. PowerFaids does not allow disbursement unless the Common Origination and Disbursement file from EdExpress is marked accordingly. Moving forward, disbursement files from COD will be reviewed daily and any disbursement records found to have errors will be resolved immediately. This will prevent future disbursement date errors with COD. Financial Aid moved to the PowerFaids system beginning with the Summer 2024 Term. With that move, new processes were implemented that will help to prevent this issue in the future.

View Audit 340598

Finding 520793 (2024-003)

Significant Deficiency 2024

Central District Health Department

NE

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Views of Responsible Officials The Health Department agrees with this finding. Corrective Action Plan The Health Department will establish a system of internal controls to identify grants which do not allow the reimbursement of indirect costs. After the auditor brought forth this instance of noncomp...

Views of Responsible Officials The Health Department agrees with this finding. Corrective Action Plan The Health Department will establish a system of internal controls to identify grants which do not allow the reimbursement of indirect costs. After the auditor brought forth this instance of noncompliance, the Health Department immediately contacted the Nebraska Department of Health and Human Services to establish a plan for corrective action. Name of Responsible Individual Teresa Anderson, Health Director Anticipated Completion Date January 31, 2025

View Audit 340597 Questioned Costs: $1

Finding 520789 (2024-001)

Material Weakness 2024

Bow School District

NH

Questioned Costs Procurement, Suspension & Debarment

The Bow School District will ensure that vendors awarded contracts are not on the suspended or debarred list. We will utilize the available listing of non-allowed vendors provided by the Federal Department of Education. Once checked, we will print our the website proof that the vendor is allowable.

View Audit 340584 Questioned Costs: $1

Finding 520786 (2024-002)

Significant Deficiency 2024

Davidson County, North Carolina

NC

Questioned Costs Significant Deficiency

Finding: 2024-002 The County did not perform Strengths + Needs Assessments on four participants for the Work First Family Assistance (TANF) program. All participants were eligible for benefits. Name of Contact Person: Patricia Baker Policy The County is responsible for completing the DSS-5298, Work ...

Finding: 2024-002 The County did not perform Strengths + Needs Assessments on four participants for the Work First Family Assistance (TANF) program. All participants were eligible for benefits. Name of Contact Person: Patricia Baker Policy The County is responsible for completing the DSS-5298, Work First Family Assessment of Strengths and Needs, within six weeks from the date of application, and no less often than once every twelve weeks of the case being open for Employment Services. The DSS-5298 should be reviewed and updated at least every twelve weeks in coordination with the quarterly update to the Mutual Responsibility Agreement/Outcome Plan. Cause Due to inexperienced staff, the Strengths and Needs (DSS-5298) form was not completed accurately and timely for (4) Work First Family Assistance cases. Corrective Action Plan All Work First Family Assistance staff have reviewed the pending and active Work First Family Assistance cases to ensure the Strengths and Needs assessment has been completed. If it was not completed, staff will follow up at the next review/appointment time with the households to ensure compliance. All Work First Family Assistance staff completed classroom training related to Work First Family Assistance policy, including required forms necessary to determine and continue eligibility for assistance. This training was completed between July and October 2024. There is currently (1) full time staff working the Work First Family Assistance caseload. There is (1) vacancy, and (1) additional staff who assists on a limited basis with reviews and child-only cases. Leadership has reviewed the DSS-5298 requirement with applicable staff to ensure their knowledge and understanding of this required form to be present and reviewed with active case participants. Timeframe Policy + remedial training was completed upon discovery of this information being missing in June 2024. Training occurred in person, by the Family Support Services Supervisor, between July and October 2024. Follow Up Training and Quality Assurance staff will continue to monitor Work First Family Assessment cases by completing second party reviews for 25% of case actions completed. This includes applications, reviews, and changes for Work First Family Assistance cases. Second Party Audit scores will be shared directly with staff and Leadership to determine additional training needs, as applicable. Second Party Audit data will be stored in a Shared Folder, and reviewed by Leadership monthly. Proposed Completion Date: With continuous monitoring and implementation of policy and procedural training that was completed in July-October 2024, Davidson County will be in compliance with the Strengths and Needs Assessment requirement for Work First Family Assistance.

View Audit 340576

Finding 520757 (2024-001)

None 2024

State Technical College of Missouri

MO

Questioned Costs Student Financial Aid Eligibility

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted two students out of forty were not disbursed the correct Pell Grant a...

2024-001 Incorrect Pell Disbursement Amount - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2024 Condition Found During our student file testing we noted two students out of forty were not disbursed the correct Pell Grant award. Based on the student’s enrollment status and need, the College under awarded the students by $716. We consider this to be an instance of noncompliance relating to the Eligibility Compliance Requirement. Corrective Action Plan The Financial Aid Office will implement a more comprehensive process to review schedule and FAFSA change reports to identify any impact on Pell awards for affected students. Responsible Person for Corrective Action Plan Heather Kleekamp, Director of Financial Aid Implementation Date of Corrective Action Plan January 2, 2025

View Audit 340518

Finding 520756 (2024-002)

None 2024

State Technical College of Missouri

MO

Questioned Costs Reporting Internal Control / Segregation of Duties

2024-002: Enrollment Reporting - Student Financial Aid Cluster – Assistance Listing Number 84.007, 84.033, 84.063, and 84.268 - Year Ended June 30, 2024 Condition Found During our Enrollment Status Changes testing, we selected forty students for our sample. In our sample of forty we tested twenty gr...

2024-002: Enrollment Reporting - Student Financial Aid Cluster – Assistance Listing Number 84.007, 84.033, 84.063, and 84.268 - Year Ended June 30, 2024 Condition Found During our Enrollment Status Changes testing, we selected forty students for our sample. In our sample of forty we tested twenty graduated students to verify that they were reported within sixty days and we tested twenty current students to note that their student status is reported correctly. We noted one student was not reported within the required sixty days. We consider this finding to be an instance of noncompliance relating to the Reporting Compliance Requirement. Corrective Action Plan The Financial Aid Office will implement a secondary review process of reconciling enrollment status reports with the current enrollment status of all students. Responsible Person for Corrective Action Plan Heather Kleekamp, Director of Financial Aid Implementation Date of Corrective Action Plan January 2, 2025

View Audit 340518

Finding 520705 (2024-004)

Material Weakness 2024

Isd 2364 - Belgrade-Brooten-Elrosa

MN

Questioned Costs Internal Control / Segregation of Duties

1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Internal control measures will be adjusted to identify construction projects funded by federal resources and to guarantee that project specifications include...

1. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding: Internal control measures will be adjusted to identify construction projects funded by federal resources and to guarantee that project specifications include the necessary components for prevailing wages. 3. Official Responsible for Ensuring CAP: Patrick Walsh, Superintendent, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP: The planned completion date for the CAP is June 30, 2025. 5. Plan to Monitor Completion of CAP: The School Board will be monitoring this CAP.

View Audit 340444

Finding 520691 (2024-001)

Material Weakness 2024

Lakeview Soil and Water Conservation District

OR

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Views of REsponsible Officials and Planned Corrective Actions. We agree with this finding. LSWCD has a good Financial Manager familiar with operations of soil and water conservation districts. LSWCD will provide online and other training for the Financial Manager to gain knowledge of governmental ac...

Views of REsponsible Officials and Planned Corrective Actions. We agree with this finding. LSWCD has a good Financial Manager familiar with operations of soil and water conservation districts. LSWCD will provide online and other training for the Financial Manager to gain knowledge of governmental accounting, federal single audit requirements, and USGAAP in an effort to accurate financial statements, reduce audit costs, and avoid errors in and omissions of year-end accruals. provide

View Audit 340383

Finding 520661 (2024-002)

Significant Deficiency 2024

Martin County

NC

Questioned Costs Allowable Costs / Cost Principles Eligibility

2024-002 Inadequate Documentation Maintained. Name of Contact Person - Angela Ellis, DSS Director. The DSS department will offer additional training to all case workers to ensure proper documentation requirements and proper review procedures are being followed to ensure files are properly maintai...

2024-002 Inadequate Documentation Maintained. Name of Contact Person - Angela Ellis, DSS Director. The DSS department will offer additional training to all case workers to ensure proper documentation requirements and proper review procedures are being followed to ensure files are properly maintained going forward. Employees will be retrained on what files should contain and the importance of complete and accurate record keeping. In addition, additional training will be provdied on online verifications, documented resources of income and those amounts agree to information in NC FAST. Proposed Completion Date: March 31, 2025

View Audit 340373

Finding 520651 (2024-003)

Material Weakness 2024

Mountain Community Health Partnership, Inc.

NC

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

In Finding 2024-003, it was reported that the Organization did not properly apply the sliding fee discount for two sliding fee patients tested. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2024-003, proper training will be given to employe...

In Finding 2024-003, it was reported that the Organization did not properly apply the sliding fee discount for two sliding fee patients tested. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2024-003, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.

View Audit 340339

Finding 520646 (2024-003)

Significant Deficiency 2024

North Country Food Bank, Inc.

MN

Internal Control / Segregation of Duties Questioned Costs Eligibility

Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures to ensure all applications are maintained and the file checklist is completed for all TEFAP Agency files. Completion Date: Immediately

View Audit 340321

Corrective Action Plans

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