Corrective Action Plans

Finding 392489 (2023-015)

Material Weakness 2023

City of Laurel

MT

Subrecipient Monitoring Reporting

NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply...

NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: December 1, 2024

View Audit 302828

Finding 392395 (2023-002)

Significant Deficiency 2023

Sicangu Oyate Ho, INC

SD

Reporting Significant Deficiency

Management Response: The School will ensure that the Single Audit reporting package is completed and submitted within the timeline as required by Uniform Guidance. Anticipated Completion Date: March 31, 2025 Responsible Party: Maria Walking Eagle, Business Manager

View Audit 302745

Finding 392393 (2023-002)

Significant Deficiency 2023

Wyoming Department of Transportation

WY

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.208 § 200.339

Upon learning of the requirement for the Federal Funding Accountability and Transparency Act (FFATA) reporting, the Highway Safety (HS) office completed the reporting in January 2024. The highway safety office completed FFATA reporting for grants from 2019-2023 which resulted in nine sub-awards bein...

Upon learning of the requirement for the Federal Funding Accountability and Transparency Act (FFATA) reporting, the Highway Safety (HS) office completed the reporting in January 2024. The highway safety office completed FFATA reporting for grants from 2019-2023 which resulted in nine sub-awards being reported. Going forward HS will complete the FFATA reporting after the subaward agreement is signed. During the year, HS will review agreements for additional obligations and update the FFATA reporting as necessary. Also, at the end of the year HS will conduct a final review to ensure all FFATA reporting was completed. Additionally, the Internal Review (IR) program has met with all of the grant administrators on January 29, 2024 to let them know about the FFATA requirements for each of their funding types. IR discussed the FFATA reporting requirement for sub-awards over $30,000. Each grant administrator will determine the best way to report their sub-awards in the Federal Subaward Reporting System (FSRS). Contact: Karson James, Highway Safety Grants Coordinator, Highway Safety and Mariá LaBorde, Internal Review Manager, Internal Review Anticipated Completion Date: January 29, 2024

View Audit 302740

Finding 392335 (2023-001)

None 2023

Averett University

VA

Reporting

Averett University Corrective Action Plan U.S. Department of Education Averett University respectfully submits that following corrective action plan for the year ended June 30, 2023. Audit Period: June 30, 2023 2023-001 Lack of timely filing of Data Collection Form to the Federal Audit Clearinghouse...

Averett University Corrective Action Plan U.S. Department of Education Averett University respectfully submits that following corrective action plan for the year ended June 30, 2023. Audit Period: June 30, 2023 2023-001 Lack of timely filing of Data Collection Form to the Federal Audit Clearinghouse Criteria: A Single Audit requires the submission of the Date Collection Form (DCF) to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of an auditor’s report, or nine months after the end of the audit period, unless a different period is specified in a program-specific audit guide. Condition: The DCF for fiscal year 2022-2023 was not submitted to the FAC within the required timeline. Action Taken: Current staffing has been increased to improve the timely preparation and submission of the audit data. The late submission for Fiscal Year 22-23 was an anomaly, the result of what could be called the perfect storm. The Controller resigned on Jun e30, 2023, following within days, by the departure of a Senior Accountant. Adding to the problem, the institution is in the throes of implementing a new ERM. Operations are stabilizing now, even though the CFO/COO resigned April 1, 2024. Filling the vacant CFO/COO position and other vacancies within the Business Office are being given top priority. Again, the untimely filing of FY23 was an anomaly that will not be repeated in further fiscal years. Responsible Party: Dr. Tiffany M. Franks Point of Contact: Gary McCombs Expected date of correction: 6-30-24

View Audit 302674

Finding 392300 (2023-001)

Significant Deficiency 2023

Southern Union State Community College

AL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Dealing with multiple HEERF grants was challenging because each grant required recording in a separate restricted fund. The college omitted one of these funds from the December 2022 quarterly HEERF report. The accountant for restricted grants did not realize a $71,280 purchase order was paid before ...

Dealing with multiple HEERF grants was challenging because each grant required recording in a separate restricted fund. The college omitted one of these funds from the December 2022 quarterly HEERF report. The accountant for restricted grants did not realize a $71,280 purchase order was paid before the end of the quarter, resulting in inaccurate reporting for the quarter. For future reports, the accountant for restricted grants will review all open purchase orders for payment to ensure that paid expenses are correctly included on the published report.

View Audit 302624

Finding 392296 (2023-002)

Significant Deficiency 2023

Southern Union State Community College

AL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The Student Financial Aid department will address the circumstances of the finding by working with the institution’s primary contact at the National Student Clearinghouse before Fall 2024. They will review and establish a scheduled transmission of reporting to meet the standards of The Department of...

The Student Financial Aid department will address the circumstances of the finding by working with the institution’s primary contact at the National Student Clearinghouse before Fall 2024. They will review and establish a scheduled transmission of reporting to meet the standards of The Department of Education Title IV programs. The Financial Aid Director and Registrar will work closely together to revise the unofficial withdrawal process before Fall 2024. The new process should ensure unofficial withdrawals are reported promptly, with accurate data, and within the roster file, based on the 50% midpoint of the semester instead of the last date of attendance. Testing will be conducted randomly during Fall 2024 to ensure the accuracy of the new process and the information reported in each roster file.

View Audit 302624

Finding 392292 (2023-004)

None 2023

Carlyle Community Unit School Dist. #1

IL

Reporting Internal Control / Segregation of Duties

We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. The District will take the necessary steps to file all quarterly expenditure reports on time in the future.

View Audit 302582

Finding 392291 (2023-001)

Significant Deficiency 2023

L.b.s.h. Housing Corporation

NY

Reporting

Management will work with their independent auditor to ensure that a proper data collection form will be submitted on a timely basis for the 2023 audit.

View Audit 302569

Finding 392277 (2023-003)

None 2023

Drake Manor Housing Development Fund Corporation

MA

HUD Housing Programs Reporting

Name of Auditee: Drake Manor Housing Development Fund Corporation Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Brian Tasso, Controller Phone: 781-932-9229 (A) Current Finding on the Schedule of Findings and Responses (3) Audit ...

Name of Auditee: Drake Manor Housing Development Fund Corporation Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Brian Tasso, Controller Phone: 781-932-9229 (A) Current Finding on the Schedule of Findings and Responses (3) Audit Finding 2023-003 - Financial Reporting (d) Comments on the finding and recommendation: Management agrees with the finding. (e) Actions Taken: Management has taken appropriate actions to timely submit the audit information. (f) Anticipated Completion Date: Management anticipates timely filing the required financial information for December 31, 2023 by the due date of March 31, 2024.

View Audit 302540

Finding 392255 (2023-001)

Significant Deficiency 2023

Pueblo of Laguna Department of Education

NM

Reporting

2023-001 – Reporting Corrective Action: The Grants Manager has updated our internal worksheet used for preparation of the SF-425 for our BIE programs so that the Repair and Replacement of Indian Schools expenditures are reported. The Grants Manager has also developed a reporting matrix for all of th...

2023-001 – Reporting Corrective Action: The Grants Manager has updated our internal worksheet used for preparation of the SF-425 for our BIE programs so that the Repair and Replacement of Indian Schools expenditures are reported. The Grants Manager has also developed a reporting matrix for all of the Department’s grants, including the semi-annual Head Start grants. Person Responsible: Eric Olson, Controller/Grants Manager Completion Date: June 30, 2024

View Audit 302511

Finding 392222 (2023-001)

Significant Deficiency 2023

Voices of Stephenson County

IL

Internal Control / Segregation of Duties Reporting

It is not economically feasible to hire additional staff to resolve the segregation of duties issue. The board will continue to review financial statements, budget vs. actual results, bank reconciliations and expense reports. See full Corrective Action Plan on district letterhead.

View Audit 302435

Finding 392216 (2023-001)

Significant Deficiency 2023

Appalachian Regional Healthcare System, Inc.

GA

Questioned Costs Allowable Costs / Cost Principles Reporting

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guideli...

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines with supporting documentation retained. • Action Taken: Management agrees with this finding as stated and the additional actions that will be taken by the System. Management will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. Rick Cassady, CFO

View Audit 302428 Questioned Costs: $1

Finding 392167 (2023-001)

Material Weakness 2023

Bandon Community Health Center Dba Coast Community Health Center

OR

Special Tests & Provisions Material Weakness Reporting

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all...

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. Anticipated completion date March 31, 2024 Contact person responsible for corrective action Kendra Newbold, Interim CEO

View Audit 302373

Finding 392148 (2023-005)

Material Weakness 2023

City of Baldwin Park

CA

Subrecipient Monitoring HUD Housing Programs Reporting § 200.327

2023-005 - Reporting – Internal Control and Compliance over Reporting (Material Weakness) Condition: Community Development Block Grants-Entitlement Grants Cluster The City did not submit the required Cash on Hand Quarterly Report in a timely manner. The quarterly Cash on Hand Quarterly Report for th...

2023-005 - Reporting – Internal Control and Compliance over Reporting (Material Weakness) Condition: Community Development Block Grants-Entitlement Grants Cluster The City did not submit the required Cash on Hand Quarterly Report in a timely manner. The quarterly Cash on Hand Quarterly Report for the all of the four (4) reporting periods were submitted on February 26, 2024. The City did not submit any of the four (4) quarterly Section 15011 Reports for the year ended June 30, 2023. Housing Voucher Cluster The audited Financial Data Schedule (FDS) for the fiscal year ended June 30, 2022 was not submitted on or before the March 31, 2023 due date. The unaudited Financial Data Schedule (FDS) for the fiscal year ended June 30, 2023 was not submitted on or before the August 31, 2023 due date. We also noted for 2 out of 4 VMS reports tested, there was no evidence of review and approval prior to submission to HUD. A nonstatistical sample of 4 out of 12 VMS reports were selected for test work. Management concurs. Corrective Actions: Due to large staff turnover in the Housing Department and Finance Department during the last 2 years, the reporting has been delayed. The City will submit all the approved reports stated above timely going forward. Name of Responsible Person: Ron Garcia, Director of Community Development Imelda Delgado, Housing Manager Rose Tam, Director of Finance Albert Trinh, Accounting Manager Projected Implementation Date: Immediately implemented.

View Audit 302364

Finding 392131 (2023-004)

Material Weakness 2023

Tgu Public School District No. 60

ND

Special Tests & Provisions Material Weakness Reporting § 200.326

Official Responsible for Ensuring CAP Lorie Werle, business manager, will be responsible to ensure that the appropriate measures are taken. Correcting Plan The District will provide Lorie Werle, business manager, necessary training. The Planned Completion Date of CAP Immediately

View Audit 302350

Finding 392125 (2023-002)

None 2023

Central Community High School District No. 71

IL

Reporting Internal Control / Segregation of Duties

We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates.

View Audit 302324

Finding 392124 (2023-002)

Material Weakness 2023

The Arc of Atlantic County, Inc.

NJ

Reporting Internal Control / Segregation of Duties

The following actions will be taken to address this process. A formalized closing process, completed on both a monthly and annual basis for all financial statement areas, has been initiated. To aid in this process, the accounting software suite used by the organization was expanded to add additional...

The following actions will be taken to address this process. A formalized closing process, completed on both a monthly and annual basis for all financial statement areas, has been initiated. To aid in this process, the accounting software suite used by the organization was expanded to add additional financial reporting modules. In addition, formal modifications have been made to the closeout process. These modifications will include the addition of new support schedules for all significant accounts. To ensure proper segregation, the schedules will be prepared and reviewed by separate individuals with the organization. As part of this new process, these support schedules will be reviewed to ensure consistency with the corresponding general ledger account. Any variances that are identified will be immediately resolved. Management is confident that the actions undertaken will improve the internal controls and financial reporting process of the organization.

View Audit 302297

Finding 392120 (2023-001)

Significant Deficiency 2023

Adkins Village Non‐profit Housing Corporation

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule ...

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is number consistently with the number assigned in the schedule. Finding - Federal Awards Finding 2023-001 – Significant Deficiency Recommendation: We recommend the Organization put procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. Action to be Taken: The Organization concurs with the facts of this finding and has put procedures

View Audit 302288

Finding 392109 (2023-002)

Material Weakness 2023

Belpre City School District

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.102 § 200.207

Finding Number: 2023-002 Planned Corrective Action: We are confident that our ESSER expenditures align with the allowable purposes and intents of the grant application that was submitted in the CCIP. We also stand by the integrity of our identification of expenses in total in the American Rescue Pla...

Finding Number: 2023-002 Planned Corrective Action: We are confident that our ESSER expenditures align with the allowable purposes and intents of the grant application that was submitted in the CCIP. We also stand by the integrity of our identification of expenses in total in the American Rescue Plan ESSER Federal Grant Program despite differences identified between grant years. The FER process and the reallocation of funds by grant year was confusing. However, as in the response above, we recognize the responsibility to adhere to the strict timelines was our responsibility. All ESSER funds have now been expended and we are confident they are allowable expenses per the guidelines provided. The Treasurer, Superintendent, and Federal Funds Coordinator agree to work more collaboratively to ensure our expenditures are within the grant timeframes prior to FER submissions. Anticipated Completion Date: 03/08/2024 Responsible Contact Person: Lance A. Erlwein, Treasurer

View Audit 302269

Finding 392105 (2023-002)

Material Weakness 2023

Healthreach Community Health Centers

ME

Reporting

Finding: 2023-002 Condition: Two of the three annual Federal Financial Reports (FFR) tested included certain amounts which were not supported by underlying accounting records. The reports were to be completed on the accrual basis of accounting; however, based on procedures performed, it was determi...

Finding: 2023-002 Condition: Two of the three annual Federal Financial Reports (FFR) tested included certain amounts which were not supported by underlying accounting records. The reports were to be completed on the accrual basis of accounting; however, based on procedures performed, it was determined the reports were completed on the cash basis of accounting. Individual(s) Responsible for Corrective Action: Donna Williams, Director of Finance Planned Corrective Action: HealthReach implemented a new accounting software program during 2023 that includes a grant management module. The Director of Finance will run reports for the individual grants to ensure proper reporting on the Federal Financial Reports includes expenses that have been incurred and paid but have not yet been drawn down. Anticipated Completion Date: This process will begin with the 2023 Federal Financial Reports (due in 2024).

View Audit 302258

Finding 392101 (2023-001)

Significant Deficiency 2023

Winslow Unified School District No. 1

AZ

Questioned Costs Cash Management Reporting

FINDINGS—FEDERAL AWARDS 2023-001: Reporting Type of Finding: Noncompliance, significant deficiency Condition/Context: The District overclaimed meals served by 16 lunches, resulting in an overpayment of $71. Action planned in response to finding: The District will evaluate its internal control proced...

FINDINGS—FEDERAL AWARDS 2023-001: Reporting Type of Finding: Noncompliance, significant deficiency Condition/Context: The District overclaimed meals served by 16 lunches, resulting in an overpayment of $71. Action planned in response to finding: The District will evaluate its internal control procedures over the preparation of meal reimbursement claims to eliminate clerical errors to ensure that the meals claimed to the Arizona Department of Education are accurately reported. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Casey Hancock, Business Manager

View Audit 302249 Questioned Costs: $1

Finding 392068 (2023-001)

Significant Deficiency 2023

Center for Workforce Inclusion, Inc.

MD

Cash Management Reporting

For the year ended June 30, 2023 closing, CWI transitioned to newaccounting software. As part of the transition, we discovered an additional reconciling item after thefourth quarter financial information was submitted. We have modified our reconciliation proceduresfor the closing. Given our prior au...

For the year ended June 30, 2023 closing, CWI transitioned to newaccounting software. As part of the transition, we discovered an additional reconciling item after thefourth quarter financial information was submitted. We have modified our reconciliation proceduresfor the closing. Given our prior audit reports since the year ended June 30, 2015, did not have anyfindings, we believe this is an isolated incident resulting from the accounting software transition.

View Audit 302192

Finding 391988 (2023-004)

Material Weakness 2023

Wyalusing Area School District

PA

Reporting

Auditors’ Recommendation: We recommend that the District prepare general fund bank reconciliations soon after the end of each month. As part of the reconciliation process the District’s general ledger cash balances should be compared against the bank reconciliation, with any differences being immedi...

Auditors’ Recommendation: We recommend that the District prepare general fund bank reconciliations soon after the end of each month. As part of the reconciliation process the District’s general ledger cash balances should be compared against the bank reconciliation, with any differences being immediately investigated. Once complete, the bank reconciliation should be reviewed by someone independent of the preparer. School District’s response: The Business Manager, Stephanie Heller, has established a reconciliation schedule and began changing the process of the reconciliation of cash beginning in July 2023. This has been a work in process with continued staff turnover and very limited business office staff. The new timeline requires reconciliations to be completed by the end of the following month, and we have additional staff members reviewing them within the limitations of the Financial Software and its double entry process.

View Audit 302154

Finding 391986 (2023-001)

None 2023

University of Southern California

CA

Reporting § 200.329 § 200.502 § 200.510

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Earl...

Management response to finding 2023-001: Accuracy of expenditures on the Schedule of Expenditures of Federal Awards and submission of special reports for the Head Start Program Cluster Name: Head Start Federal Awarding Agency: Department of Health and Human Services Award Name: Head Start and Early Head Start, COVID (P.L. 116-260) Award Number: 09CH010228-05-05, 09CH011831-02-03, 09HE000328-01-00 Award Years: 2019-2021, 2021-2022, 2021-2023 Assistance Listing Title: Head Start Assistance Listing Number: 93.600 Pass-through entities: Not applicable As described in finding 2023-001, the University inadvertently charged and drew down budgeted capital expenditures from Head Start awards before actual expenditures were incurred by the University. Additionally, the University charged expenditures to a Head Start award after liquidation extensions had expired. The adjustments required to correct these errors were identified in the subsequent fiscal year, resulting in expenditures on the fiscal year 2023 Schedule of Expenditures of Federal Awards (SEFA) being overstated. The University will take the necessary corrective actions as described below to ensure the accuracy of expenditures reported on the SEFA. Finally, as described in finding 2023-001, the University did not identify and track reports required to be submitted for Head Start awards. The corrective actions described below will ensure all award specific reporting requirements are met. Although the University has limited federal awards that are utilized to fund capital expenditures, the Office of Sponsored Projects Accounting and Facility Planning and Management will perform a full review of the current Head Start capital construction accounting policies and practices to ensure they comply with the Uniform Guidance and the terms and conditions of federal awards before June 30, 2024. Reinforcement of the University’s policies and practices will ensure proper grant accounting, and thus, will prevent SEFA reporting adjustments from having to be made. Faculty leadership responsible for overseeing the Head Start program at the University will fill current vacant financial management positions within the Head Start program as soon as possible (with a three month target), undergo a full review of program requirements with all staff, and modify and develop new internal controls related to this finding. Specifically, before July 2024, Head Start fiscal personnel along with faculty leadership will develop a reporting schedule specific to Head Start awards, provide training and resources to staff involved with reporting, implement internal controls related to the reconciliation and validation of reported data prior to report submission, and strengthen internal controls related to the allocability of expenditures to awards (particularly in situations where liquidation extensions or expenditure carry forwards have been granted). Contact Person: Andres Chan, Director, FBS Financial Analysis, andres.chan@usc.edu

View Audit 302151

Finding 391985 (2023-002)

Material Weakness 2023

The Association of Chrmc and University Physicians

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Finding: For ALN 93.498, The actual total revenues for the quarter ended June 30, 2023 reported on the PRF period 5 submission do not agree to underlying accounting records for fiscal year ended June 30, 2023 by approximately $1,768,704. This difference affects the amount of revenues reported but d...

Finding: For ALN 93.498, The actual total revenues for the quarter ended June 30, 2023 reported on the PRF period 5 submission do not agree to underlying accounting records for fiscal year ended June 30, 2023 by approximately $1,768,704. This difference affects the amount of revenues reported but does not affect other data within the report, including the amount of PRF funds received that were utilized. Recommendation: Under the requirements of 2 CFR 200.303 the entity must establish and maintain effective internal controls over federal awards that provides reasonable assurance that the entity is in compliance with federal statues, regulation, and terms and conditions of the Federal award. Under the requirements of the PRF program reporting for an entity that uses option 1 to calculate lost revenues, the entity must report quarterly actual revenue/net charges from patient care. Corrective Action: In order to ensure that total revenues (by quarter) agree to the underlying accounting records a customized accounting system report will be developed to accurately report total revenues/net charges from patient care by quarter. A reconciliation will be performed to ensure that revenues reported agree with amounts reflected in the Association’s general ledger. Person Responsible for Corrective Action: David Sunstrom, Controller Anticipated Completion Date for Corrective Action: The Corrective Action will be implemented by June 30, 2024.

View Audit 302147

Corrective Action Plans

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