Corrective Action Plans

Finding 46156 (2022-001)

Significant Deficiency 2022

Lycoming-Clinton Counties Commission for Community Action (step), Inc.

PA

Special Tests & Provisions Questioned Costs Eligibility

COVID-19 CCDF Cluster - Assistance Listing 93.575, 93.596 passed through Pennsylvania Department of Human Services - Pass-through Grantor's Number - SAP DC21079943; Temporary Assistance for Needy Families-Assistance Listing 93.558 passed through Pennsylvania Department of Human Services - Pass-throu...

COVID-19 CCDF Cluster - Assistance Listing 93.575, 93.596 passed through Pennsylvania Department of Human Services - Pass-through Grantor's Number - SAP DC21079943; Temporary Assistance for Needy Families-Assistance Listing 93.558 passed through Pennsylvania Department of Human Services - Pass-through Grantor's Number - SAP DC21079943; Grant period Fiscal Year Ended June 30, 2022. Significant Deficiency Recommendation: STEP should ensure their file compliance review procedures include review of files at the end of periods of presumptive eligibility. Management Response: File compliance review procedures should include review of files at the end of periods of presumptive eligibility. Action Taken: STEP will ensure their file compliance review procedures will include end of periods of presumptive eligibility. Persons Responsible: Melissa Kerschner; Director ELRC Region 7; Tobi Allen, Eligibility Manager Completion Date: February 17, 2023.

View Audit 40603

Finding 46154 (2022-001)

Material Weakness 2022

Pickaway County

OH

Questioned Costs Procurement, Suspension & Debarment § 200.321 § 200.323

We will implement procedures to ensure all future contracts are properly procured under this grant. July 31, 2023 County Administrator 740-474-6093

View Audit 40211 Questioned Costs: $1

Finding 46148 (2022-001)

Significant Deficiency 2022

Signature Theatre, Inc.

VA

Questioned Costs Cash Management Period of Performance

2022-001 Revenue Recognition Views of Responsible Officials and Corrective Action Plan: Responsible Officials: Maggie Boland, Managing Director Valerie Bunns, Director of Finance and Administration Corrective Action Plan: Signature will incorporate training on ASU 2018-08, Not-for-Profit Entities (T...

2022-001 Revenue Recognition Views of Responsible Officials and Corrective Action Plan: Responsible Officials: Maggie Boland, Managing Director Valerie Bunns, Director of Finance and Administration Corrective Action Plan: Signature will incorporate training on ASU 2018-08, Not-for-Profit Entities (Topic 958) related to revenue recognition of pledges and contributions for the appropriate personnel.

View Audit 40745

Finding 46138 (2022-002)

Material Weakness 2022

Oglesby Esd No. 125

IL

Questioned Costs Matching / Level of Effort / Earmarking § 200.302

The District will create general ledger accounts to better segregate and track expenditures specific to grant programs. The District will also have grant expenditures reports reviewed by someone other than the preparer before submission.

View Audit 40647 Questioned Costs: $1

Finding 46134 (2022-004)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no dis...

2022-004 SPECIAL PROVISIONS Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that Collaborative reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Name of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 40299

Finding 46133 (2022-003)

Significant Deficiency 2022

Freeborn County

MN

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audi...

2022-003 REPORTING Medical Assistance Program ? Assistance Listing No. 93.778 Recommendation: We recommend that the County enact policies to ensure that reports are reviewed prior to submission in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2023

View Audit 40299

Finding 46123 (2022-001)

None 2022

Milestone Recovery and Subsidiaries

ME

Questioned Costs Reporting Internal Control / Segregation of Duties

Views of responsible officials and planned corrective action: We are in agreement with the finding. We are taking steps to create an updated process to ensure compliance with this requirement moving forward.

View Audit 40960

Finding 46115 (2022-001)

Material Weakness 2022

Global Community Charter School

NY

Matching / Level of Effort / Earmarking Special Tests & Provisions Questioned Costs § 200.303 § 200.320

Re: Finding 2022-001: GCCS management will retain documentation to support proper operation of internal controls and compliance with applicable Federal statutes, regulations, and terms and conditions of the awards received.

View Audit 41361

Finding 46102 (2022-002)

None 2022

Crf Xii, Inc. Dba Prov. Place of Bloomington Apartments

IN

Questioned Costs Reporting Matching / Level of Effort / Earmarking

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-002: Section 223(f) Loan Program, CFDA 14.157 Recommendation: The management agent should ensure the Project is properly maintained. Action Taken: Management is in the process of addressing the ...

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-002: Section 223(f) Loan Program, CFDA 14.157 Recommendation: The management agent should ensure the Project is properly maintained. Action Taken: Management is in the process of addressing the various items noted in the REAC inspection report.

View Audit 41495

Finding 46101 (2022-001)

None 2022

Crf Xii, Inc. Dba Prov. Place of Bloomington Apartments

IN

Questioned Costs Cash Management HUD Housing Programs

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-001: Section 223(f) Loan Program, CFDA 14.157 Recommendation: Make the deposit to the residual receipts account as required and ensure that all future residual receipts amounts are deposited with...

Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2022-001: Section 223(f) Loan Program, CFDA 14.157 Recommendation: Make the deposit to the residual receipts account as required and ensure that all future residual receipts amounts are deposited within 90 days after year end. Action Taken: Management will make the required residual receipts deposit as soon as possible and will ensure compliance in the future.

View Audit 41495

Finding 46100 (2022-004)

Significant Deficiency 2022

Eastern New Mexico University

NM

Questioned Costs Eligibility Significant Deficiency § 200.62

Corrective Action: A review of related GEAR UP grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. Additionally, records and reviews of student participation in GEAR UP activities will be performed on a monthly basis. Tim...

Corrective Action: A review of related GEAR UP grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. Additionally, records and reviews of student participation in GEAR UP activities will be performed on a monthly basis. Timeline of Corrective Action: The review of student participation will begin by November 30, 2022. Responsible Party(ies): GEAR UP Program Director; Roswell Campus

View Audit 41471

Finding 46096 (2022-003)

Significant Deficiency 2022

Eastern New Mexico University

NM

Questioned Costs Student Financial Aid Eligibility

Corrective Action: (SSS): SSS will verify student?s low-income levels for those with a FAFSA on file by having the University?s Financial Aid Department confirm that the student?s income is low-level per the Student Aid Report and FAFSA University?s Financial Aid Department confirm that the st...

Corrective Action: (SSS): SSS will verify student?s low-income levels for those with a FAFSA on file by having the University?s Financial Aid Department confirm that the student?s income is low-level per the Student Aid Report and FAFSA University?s Financial Aid Department confirm that the student?s income is low-level per the Student Aid Report and FAFSA. The EFC that is listed at $0 is information that is derived from the institution?s Financial Aid Department that is uploaded into Banner once the department verifies the information which comes from the FAFSA and parent/student taxes. (TS): Students in question were offered allowable activities (e.g., tutoring, career/college exploration) by TS program staff. However, these eight students elected to forgo involvement in permissible activities. During the audited period, the former TS program director retired and a new program director was hired. There was no overlap between the former and new program director. The TRIO Tracking Specialist reviewed, signed, and initialed documents in the absence of the TS Director. The applications audited show evidence of the initials of the TRIO Tracking Specialist which was intended to provide evidence of internal program control. Timeline of Corrective Action: 1. The above processes will be put in place by December 31, 2022. 2. A review of related TRIO grant processes and eligibility requirements for students currently involved in the programs will be conducted by June 30, 2023. 3. In addition to the above steps, the Roswell campus is in the process of reviewing the job description for a grants director to oversee federal grants. This position would include oversight of compliance with federal rules, regulations, guidelines, and campus policies. The ENMU-Roswell Campus HR office reviewed the grants director job description and started the process of posting this position on October 24, 2022. It is anticipated this position will be filled by January 31, 2023. 4. Additional compliance discussion sessions and grant requirement reviews for the involved TRIO grant program directors will take place in November 2022 with the campus senior leadership. Responsible Party(ies): Roswell Campus; Assistant Vice President of Student Affairs

View Audit 41471

Finding 46091 (2022-002)

Significant Deficiency 2022

Eastern New Mexico University

NM

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

Corrective Action: Management agrees that students were not properly reported to the Clearinghouse or NSLDS again and that all of the proposed corrective action in FY 21 did not occur. The registrar did not utilize NSLDS access until October 2022 and was not able to verify the submissions. Timeli...

Corrective Action: Management agrees that students were not properly reported to the Clearinghouse or NSLDS again and that all of the proposed corrective action in FY 21 did not occur. The registrar did not utilize NSLDS access until October 2022 and was not able to verify the submissions. Timeline of Corrective Action: Immediate. The registrar now has access to NSLDS as well as the Clearinghouse and has established procedures to verify the submission after every upload. The Financial Aid and Registrar Offices have agreed to meet quarterly to review submissions and to include Roswell offices in the meetings too. Responsible Party(ies): Registrar; Portales Campus

View Audit 41471

Finding 46090 (2022-003)

Material Weakness 2022

Total Health Care, Inc.

MD

Allowable Costs / Cost Principles Questioned Costs Reporting

Views of Responsible Officials and Planned Corrective Actions - Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight b...

Views of Responsible Officials and Planned Corrective Actions - Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the parent organization. Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.

View Audit 40855 Questioned Costs: $1

Finding 46089 (2022-002)

Material Weakness 2022

Total Health Care, Inc.

MD

Questioned Costs Reporting

Views of Responsible Officials and Planned Corrective Actions ? The Organization submitted the report within the allowable time granted by HRSA and the information provided on the report was accurate at the time the report was prepared and submitted to HRSA. An updated report with additional lost re...

Views of Responsible Officials and Planned Corrective Actions ? The Organization submitted the report within the allowable time granted by HRSA and the information provided on the report was accurate at the time the report was prepared and submitted to HRSA. An updated report with additional lost revenues, if required, will be provided to HRSA. Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.

View Audit 40855

Finding 46088 (2022-001)

Significant Deficiency 2022

Village Cooperative of Greeley

CO

Internal Control / Segregation of Duties Questioned Costs Significant Deficiency

Department of Housing and Urban Development HUD project FHA #101-23103 Village Cooperative of Greeley Federal ID# 81-5277495 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The project o...

Department of Housing and Urban Development HUD project FHA #101-23103 Village Cooperative of Greeley Federal ID# 81-5277495 The FASS system generated the following findings from its review of the August 31, 2022 financial statements. The results of the assessment are summarized below. The project owner should provide their assigned HUD Project Manager a written response addressing each of the findings, and appropriate documentation (e.g. copies of cancelled checks, bank statements, etc.) to prove the finding has been resolved. Project Auditor Findings: The auditor reported the following findings: Compliance Oriented Findings. The Schedule of Findings and Questioned Costs by the auditor contained findings related to the following Auditor Indicator Codes: Finding Reference No. / Code - Finding Condition 2022-001 / S - Internal Control Deficiencies Corrective Action(s). For all audit findings that were unresolved as of the date of the audit report, the owner must provide their HUD Project Manager a written response and supporting documentation indicating the finding has been resolved. Corrective Action Plan: The

View Audit 40957

Finding 46081 (2022-002)

Significant Deficiency 2022

Lafayette Transitional Housing Center, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN February 2, 2023 U.S. Department of Housing and Urban Development (HUD)--Continuum of Care Program Lafayette Transitional Housing respectfully submits the following corrective action plan for the year ended September 30, 2022: Name and address of Independent Public Accounting ...

CORRECTIVE ACTION PLAN February 2, 2023 U.S. Department of Housing and Urban Development (HUD)--Continuum of Care Program Lafayette Transitional Housing respectfully submits the following corrective action plan for the year ended September 30, 2022: Name and address of Independent Public Accounting Firm: Huth Thompson LLP P0 Box 970 Lafayette, IN 47902-0970 Audit period: September 30, 2022 The findings from the September 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS--FINANCIAL STATEMENT AUDIT (MATERIAL WEAKNESS) 2022-001: PREPARATION OF FINANCIAL STATEMENTS Recommendation: The Organization should follow established controls to ensure proper recognition of restricted net asset sources. Action Taken: LTHC acknowledges discrepancies in recognition of restricted net asset sources. Recommendations in the Corrective Action Plan dated February 2, 2023 were adopted and phased in beginning February 2023. We will continue to use a separate spreadsheet to track all restricted funds, which is reviewed monthly by Executive Staff. FINDINGS AND QUESTIONED COSTS-- MAJOR FEDERAL AWARD PROGRAMS AUDIT U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD)?Continuum of Care Program 14.267: REPORTING (SIGNIFICANT DEFICIENCY) Recommendation: The Organization should ensure that it has properly allocated salaries charged to grants. Corrective Action: LTHC acknowledges discrepancies in recognition of salary allocation. Recommendations in the Corrective Action Plan dated February 2, 2023 were adopted and phased in beginning February 2023. We have added an additional step to the detailed time report from APS that will verify the hours documented on the timesheets. All Corrective Actions have already been implemented. If the Department of Housing and Urban Development has questions regarding this plan, please call Jennifer Layton, President and CEO at 765-423-4880. Sincerely, Jennifer Layton President/Chief Executive Officer

View Audit 40956

Finding 46078 (2022-003)

Material Weakness 2022

East River Legal Services Corporation

SD

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

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and ...

Finding 2022-003 Federal Agency Name: Legal Services Corporation Program Name: LSC Basic Field Grant; LSC Technology Improvement Grant. CFDA#: 09-542026 Finding Summary: Total hours and LSC hours worked used to drive monthly allocation of indirect expenses by grant did not agree to total hours and LSC hours worked in the Organization?s timekeeping software for eight of the twelve months. Additionally, one instance identified in which the rate of pay paid to an employee did not agree to the approved rate of pay. Responsible Individuals: Kathy Schroeder, 3rd party accountant, and Lea Wroblewski, Executive Director. Corrective Action Plan: Additional procedures are being followed to ensure that the timekeeping software is completed on a timely basis and locked down by the Executive Director or Technology Consultant when all entries have been made and reviewed. The time report used for the indirect expense allocations is not processed until the software is locked down. All changes to employees pay calculation are made after the submission of an approved Personnel Action Form is provided to the staff accountant. Each payroll is then reviewed by the Executive Director and a board member before processing. Completion Date: 06/30/2023

View Audit 40917

Finding 46076 (2022-003)

Material Weakness 2022

School District of Random Lake

WI

Questioned Costs Special Tests & Provisions Material Weakness

Special Tests and Provisions ? Wage Rate Requirements There is no disagreement with the finding. District management will review policies and procedures in response to the finding. Additional Response Patti Degnitz, Business Manager, is the contact person for the District. She performs the followi...

Special Tests and Provisions ? Wage Rate Requirements There is no disagreement with the finding. District management will review policies and procedures in response to the finding. Additional Response Patti Degnitz, Business Manager, is the contact person for the District. She performs the following mitigating controls: 1. Reviews and approves all adjusting entries proposed by the auditor. 2. Compares final adjusted trial balance with audited financial statements. 3. Compares the schedule of expenditures of federal awards and state financial assistance to: a. Final adjusted trial balance b. Submitted final reimbursement claims c. State payment register and DPI website

View Audit 41494 Questioned Costs: $1

Finding 46075 (2022-001)

Significant Deficiency 2022

Knob Noster R-Viii School District

MA

Questioned Costs Reporting Significant Deficiency

The District will review state law, federal law and District policy as well as administrative procedures regarding enrollment of resident and non-resident students to ensure accuracy and compliance.

View Audit 41469 Questioned Costs: $1

Finding 46073 (2022-002)

Significant Deficiency 2022

Lincoln County, Nebraska

NE

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

Finding 2022-002: Coronavirus State and Local Fiscal Recovery Funds Reporting Corrective Action Planned: The Lincoln County Board of Commissioners will discuss establishing a policy for reporting requirements. They will also discuss who will file reports for the county going forward and perhaps ...

Finding 2022-002: Coronavirus State and Local Fiscal Recovery Funds Reporting Corrective Action Planned: The Lincoln County Board of Commissioners will discuss establishing a policy for reporting requirements. They will also discuss who will file reports for the county going forward and perhaps someone to review the document before submission who is not involved in the preparation of the report. Anticipated Completion Date: Ongoing ? preferably by the next reporting date in April 2023 Responsible Party: Christopher D. Bruns, Lincoln County Board Chairman

View Audit 40615

Finding 46064 (2022-001)

Significant Deficiency 2022

Charles R. Drew University of Medicine and Science

CA

Student Financial Aid Questioned Costs Special Tests & Provisions

Management?s Corrective Action Plan: The University acknowledges the finding and the recommendation from Moss Adams regarding improving procedures. Finding-2022-001 Special Tests and Provisions-Enrollment Reporting-Significant Deficiency in Internal Controls Over Compliance Improved Process of Proto...

Management?s Corrective Action Plan: The University acknowledges the finding and the recommendation from Moss Adams regarding improving procedures. Finding-2022-001 Special Tests and Provisions-Enrollment Reporting-Significant Deficiency in Internal Controls Over Compliance Improved Process of Protocol: The University will implement corrective action during November 2022 related to the filing of the NSLDS report. This will include updating monthly reporting to National Student Clearinghouse when responding to NSLDS roster files rather than every other month. Additionally, the department has revised paperwork for graduating students to ensure status are processed in a timely manner by the Registrar. Contact Person Responsible for Corrective Action: Raquel Munoz. Registrar Anticipated Completion Date: November 2022

View Audit 40248

Finding 46060 (2022-002)

None 2022

Johnstown-Cambria County Airport Authority

PA

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

Airport Improvement Program (AIP) Award 3-42-0045-055-2020 ? CFDA No. 20.106 Name of contact person ? Heather Tomasko, Assistant Manager Recommendation: We recommend that management develop a process of tracking operating expenses used for reimbursement requests and implement an internal contr...

Airport Improvement Program (AIP) Award 3-42-0045-055-2020 ? CFDA No. 20.106 Name of contact person ? Heather Tomasko, Assistant Manager Recommendation: We recommend that management develop a process of tracking operating expenses used for reimbursement requests and implement an internal control procedure to avoid duplicating expenses from previous reimbursement requests. Based on our analysis of the Authority?s 2022 operating expenses, the Authority has over $100,000 in unsubmitted/unreimbursed operating expenses that appear eligible for AIP 55 to cover the questioned costs. Therefore, we also recommend the Authority contact the Federal Aviation Administration and inquire about the procedure to revise the reimbursement requests that included duplicate expenses. Further, we recommend that management review subsequent reimbursement requests to ensure accuracy and revise, if necessary. Action Taken: Management agrees with the recommendations. Management will contact the Federal Aviation Administration to determine the process to revise the reimbursement requests using other eligible expenses. Further, we will develop an internal control procedure to prevent future errors. Proposed Completion Date: June 15, 2023.

View Audit 40645 Questioned Costs: $1

Finding 46058 (2022-003)

Significant Deficiency 2022

Colona Grade School District No. 190

IL

Questioned Costs Subrecipient Monitoring Cash Management § 200.305

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July and August 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. ...

Finding No.: 2022- 003 Condition: The District's expenditure report filed for June 30, 2022 included expenditures paid in July and August 2022. These amounts were not reported as committed or obligated. Plan: Grant expenditure reports will be prepared on the cash basis and obligations reported. The liquidation of the obligations will be reported on subsequent liquidation reports. Anticipated Date of Completion: August 31, 2022 Name of Contact Person: Dr. Mike Ruff, Superintendent Management Response: There is no disagreement with this finding and management will monitor all future federal reimbursement requests. Committed and obligated expenditures will be reported appropriately, and will be paid within 90 days after project completion.

View Audit 40633

Finding 46046 (2022-001)

Significant Deficiency 2022

Valley Children's Healthcare

CA

Questioned Costs Cash Management Reporting

As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended September 30, 2022. Management?s Views and Corrective Action Plan Finding No: 2022-001: Reporting ? Significa...

As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended September 30, 2022. Management?s Views and Corrective Action Plan Finding No: 2022-001: Reporting ? Significant Deficiency in Internal Control Over Compliance Federal Program Information Federal Agency: U.S Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year 2020-2021 Corrective Action Planned Management has implemented a corrective action plan. Management has added an additional layer of review control over the completeness and accuracy of expenditures and calculations included in all submissions. Person Responsible for Corrective Action: Stephanie Vance, VP Finance Anticipated Completion Date: September 30, 2022

View Audit 51260

Corrective Action Plans

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