Corrective Action Plans

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

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View Audit 12942

Finding 9454 (2023-002)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. Th...

All front desk staff will complete comprehensive training on applying the Sliding Fee Discount Policy to patient fees. Supervisors will conduct a competency check with each staff member and retain a signed competency form on the Sliding Fee Discount Schedule (SFDS) policy in their personnel file. This will be complete by the end of January 2024 and incorporated into onboarding and orientation for new hires moving forward (to be completed within two weeks of the start date).

View Audit 12942

Finding 9454 (2023-002)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow ...

Front desk supervisors at all clinic sites will be responsible for doing a weekly audit of fee collection amounts to ensure that visit fees are being collected appropriately according to the Sliding Fee Discount Policy. We will work to re-institute a regular copay report which will improve the flow of information between the front desk, IT / data, and the fiscal teams, allowing for more timely

View Audit 12942

Finding 9401 (2023-002)

Significant Deficiency 2023

D H, Incorporated

OR

HUD Housing Programs Reporting Significant Deficiency

Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be s...

Finding 2023-002 Response Type of Finding: Significant deficiency in internal control over compliance and instance of immaterial noncompliance. Criteria: DHI’s regulatory agreement with HUD and the HUD Uniform Financial Reporting Standards (24 CFR §5.801) require audited financial statements to be submitted to HUD within 90 days of the fiscal year end. HUD may authorize an extension to the 90 day due date. Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. ShelterCare, as managing agent, has hired a new property accountant which should help with keeping the books current and ShelterCare prepared to start audit work mid-July and be ready to submit the audit to HUD within 90 days of the fiscal year end. 3. The anticipated completion date: a. New property accountant was hired in August of 2023.

View Audit 12871

Finding 9373 (2023-005)

Significant Deficiency 2023

Somerset Academy of Las Vegas

NV

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...

Finding Number: 2023-005 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 12842

Finding 9363 (2023-004)

Significant Deficiency 2023

Sports Leadership and Management Academy of Nevada

NV

Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency § 200.303

Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grant...

Finding Number: 2023-004 Approval Of Expense Transactions Corrective Action Plan: A process was put in place in May 2023 to ensure that all principal approvals are documented in writing or electronic approval in the system which can be date stamped by the system. Payroll will not be run, nor grants submitted, until proper approval is received. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 12841

Finding 9341 (2023-003)

Significant Deficiency 2023

Sports Leadership and Management Academy of Nevada

NV

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the ...

Finding Number: 2023-003 – Review and Approval of the Schedule of Expenditures of Federal Awards (SEFA) Corrective Action Plan: While there was a review of the SEFA, the documentation of said review did not occur properly. Management has put in place a process to document preparation/review of the SEFA evidenced by signature and date. Personnel Responsible for Corrective Action: Nachum Golodner, Academica Director of Accounting Anticipated Completion Date: June 30, 2024

View Audit 12841

Finding 9337 (2023-002)

Significant Deficiency 2023

Paris Junior College

TX

Student Financial Aid Cash Management Reporting

Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to ...

Corrective Action Plan (Continued) Year Ended August 31, 2023 2023-02 Recommendations: Paris Junior College's management should implement additional controls and procedures to ensure compliance requirements are met regarding the posting of contracted arrangements with financial account providers to the Department of Education's database. Additionally, the College must establish a procedure to accomplish a due diligence review of the financial account provider's rates and fees. Action Plan: Paris Junior College management will ensure that a comprehensive procedure is established and implemented to ensure compliance requirements are met. Contact Person: Debra Craig, Controller Anticipated Completion Date: January 10, 2024

View Audit 12826

Finding 9314 (2023-003)

Significant Deficiency 2023

North Central Michigan College

MI

Student Financial Aid Eligibility Significant Deficiency

Auditor Description of Condition and Effect. Instead of earning additional aid due to the Return of Title IV calculation error, one of the twenty one students who were affected saw a reduction due to a transposition/rounding error that was missed in the original calculation. As a result of this cond...

Auditor Description of Condition and Effect. Instead of earning additional aid due to the Return of Title IV calculation error, one of the twenty one students who were affected saw a reduction due to a transposition/rounding error that was missed in the original calculation. As a result of this condition, input errors for the Return of Title IV calculations can make it through the process without being discovered. It is our understanding that on July 26, 2023, the College corrected the transposition/rounding error that impacted the students Return of Title IV calculation. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the student impacted by the input error. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9308 (2023-002)

Significant Deficiency 2023

North Central Michigan College

MI

Special Tests & Provisions Significant Deficiency Equipment & Real Property Management

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of multi-factor authentication for anyone accessing customer information on the institution's system, conducting a periodic inventory of data that notes where it is collected, ...

Auditor Description of Condition and Effect. The most recent Gramm Leach Bliley Policy fails to address the implementation of multi-factor authentication for anyone accessing customer information on the institution's system, conducting a periodic inventory of data that notes where it is collected, store, or transmitted, encrypting customer information on the institution's system and when it's in transit, and the assessment of apps developed by the institution. As a result of this condition, the College isn't meeting the safeguard requirements necessary to comply with the FTC. In addition, the lack of safeguard controls creates an increased risk to highly sensitive data that is possessed by the College. Auditor Recommendation. We recommend that the College implement procedures to ensure that all Gramm Leach Bliley Policies are met and verified by a second individual. Corrective Action. Currently, the College is reviewing the compliance requirements for Gramm Leach Bliley and will amend the current policy to ensure that each safeguard is being addressed within the policy. Responsible Person. Alex Freds, Director of IT Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9302 (2023-001)

Significant Deficiency 2023

North Central Michigan College

MI

Student Financial Aid Eligibility Reporting

Auditor Description of Condition and Effect. For the Winter 2023 semester, a break of 5 days (excluding weekends) was being subtracted instead of 9 days (including weekends) from the total days in the term, which resulted in the calculation being incorrect for all students who had returns in the Win...

Auditor Description of Condition and Effect. For the Winter 2023 semester, a break of 5 days (excluding weekends) was being subtracted instead of 9 days (including weekends) from the total days in the term, which resulted in the calculation being incorrect for all students who had returns in the Winter 2023 semester. As a result of this condition, Return of Title IV calculations were incorrect for 21 students for the Winter 2023 semester, resulting in $4,265 in excess funds returned to the U.S. Department of Education. It is our understanding that on July 26, 2023, the College repaid the 21 students affected by this calculation error. Auditor Recommendation. Management has already taken appropriate corrective action by updating the returns for the 21 students impacted by the calculation error in the Winter 2023 Semester. However, we recommend that the College implement a review process to ensure that the R2T4 calculation is being reviewed by a second individual. Corrective Action. The College has performed the necessary steps to correct the error and will amend the calculation process to ensure that a second individual is reviewing the work performed. Responsible Person. Katie Malone, Director of Student Aid Anticipated Completion Date. June 30, 2024

View Audit 12796

Finding 9290 (2023-004)

Significant Deficiency 2023

Family First Health Corporation

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Planned Corrective Action: This was a repeat finding for Family First Health. Going forward future submissions will be reviewed for accuracy prior to submitting. Completion Date: 4/1/2024 Accounting Name of Contact Person: Jenny Englerth, President/CEO; Brent Doores, CFO

View Audit 12740

Finding 9234 (2023-002)

Significant Deficiency 2023

Scotland County Board of Education

NC

Subrecipient Monitoring Cash Management Reporting

Name of Contact Person :Wannaa Chavis, Chief Finance Officer ...

Name of Contact Person :Wannaa Chavis, Chief Finance Officer Corrective Acrtion Plan: The finding resulted primarily from significant turnover within the Finance Department. Management has established procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completion Date: Immediately

View Audit 12648

Finding 9229 (2023-003)

Significant Deficiency 2023

Marlette Regional Hospital

MI

Internal Control / Segregation of Duties Reporting Significant Deficiency

Finding 2023.003 Response: When reporting for Federal awards moving forward, before submitting the final report, payroll will review all payroll data that was submitted to the CFO. The human resources department will double check to ensure accuracy of the employees being reported. Responsible Par...

Finding 2023.003 Response: When reporting for Federal awards moving forward, before submitting the final report, payroll will review all payroll data that was submitted to the CFO. The human resources department will double check to ensure accuracy of the employees being reported. Responsible Party: Kim Gentner, CFO at Marlette Regional Hospital Estimated Completion: 01/01/2024

View Audit 12640

Finding 9216 (2023-001)

Significant Deficiency 2023

Catholic Charities

OR

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2023. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2023 Major Federal Award Findings: Finding Reference #: 202...

Catholic Charities respectfully submits the following corrective action plan for the year ended June 30, 2023. Name & address of public accounting firm: Kernutt Stokes 1600 Executive Parkway, Suite 110 Eugene OR 97401 Audit Period: June 30, 2023 Major Federal Award Findings: Finding Reference #: 2023-001 Significant deficiency Recommendation: We recommend management design and implement internal controls over compliance to ensure the amount of $873 is deposited monthly into the Replacement Reserve account as required by HUD. Corrective Action: Management will work with Cascade Management to improve the internal control procedures to ensure the amount of $873 is deposited monthly into the Replacement Reserve account as required by HUD. Questions regarding this corrective action plan may be directed to Marci Pierce, Chief Financial and Administrative Officer, at (503) 688-2646.

View Audit 12592

Finding 9151 (2023-001)

Significant Deficiency 2023

Connstep, Inc.

CT

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a mo...

United States Department of Commerce 2023-001 Connecticut State Technology Extension Program – Assistance Listing No. 11.611 Recommendation: We recommend that if employees are being allocated to multiple programs throughout the year, personnel activity reports must be prepared at minimum, on a monthly basis and be reviewed and signed off on by both the employee and their immediate supervisor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a policy to require employees to prepare activity reports on a least a monthly basis that are signed by the employee and the supervisor. Name of the contact person responsible for corrective action: Robert Blakey, Controller Planned completion date for corrective action plan: December 2023.

View Audit 12525

Finding 9122 (2023-001)

Significant Deficiency 2023

Northwest Community Schools

MI

Cash Management Reporting School Nutrition Programs

Finding: 2023-001 – Reporting – Meal Claim Reimbursement Noncompliance Auditor Description of Condition and Effect. Two of three meal claim reimbursement reports selected for testing did not agree to underlying meal count sheets and on all three reports tested, the District understated claims for o...

Finding: 2023-001 – Reporting – Meal Claim Reimbursement Noncompliance Auditor Description of Condition and Effect. Two of three meal claim reimbursement reports selected for testing did not agree to underlying meal count sheets and on all three reports tested, the District understated claims for one of its facilities. As a result of this condition, the District submitted inaccurate claims for reimbursement, resulting in a reimbursement less than what the District should have received. Auditor Recommendation. We recommend that the District thoroughly review its monthly reports to count sheets and familiarize itself with allowable reimbursement claims. Corrective Action. Management concurs with finding. The District will utilize a thorough review of entered data prior to certification of claims data. A secondary review of claims data will be reviewed by a District finance department staff to ensure proper claims data. Responsible Person: Emili Jones, Director of Business and Finance Anticipated Completion Date: November 1, 2023

View Audit 12482

Finding 9101 (2023-002)

Significant Deficiency 2023

Napoleon Community Schools

MI

Questioned Costs Special Tests & Provisions Significant Deficiency

Finding: 2023-002 – Special Tests and Provisions - Wage Rate Requirements U.S. Department of Education– COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through MDE; All project numbers. Auditor Description of Condition and Effect: One of the contracts selected for testing...

Finding: 2023-002 – Special Tests and Provisions - Wage Rate Requirements U.S. Department of Education– COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through MDE; All project numbers. Auditor Description of Condition and Effect: One of the contracts selected for testing that was subject to the Wage Rate Requirements did not include the required provision and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: Management will work internally with the management team on all construction contracts greater than $2,000. At time of quote or contract Management will determine if the funding source is Federal and apply the appropriate Davis Bacon Act - Prevailing Wage Compliance Certification. Management will follow up with the vendor to obtain the required certified payrolls. Responsible Person: Kendra Leib, LEA Business Manager Anticipated Completion Date: June 30, 2024

View Audit 12452 Questioned Costs: $1

Finding 9099 (2023-002)

Significant Deficiency 2023

Anne Arundel Community College

MD

Special Tests & Provisions Student Financial Aid Reporting § 200.303

2023-002: Special Tests and Provisions – NSLDS Program-Level Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: The associate degree programs were not reported as two years per the recommendation in the NSLDS enrollment reporting guide. Recommendation: We rec...

2023-002: Special Tests and Provisions – NSLDS Program-Level Reporting Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268 Condition: The associate degree programs were not reported as two years per the recommendation in the NSLDS enrollment reporting guide. Recommendation: We recommend the College report associate degree program length to NSLDS at two years. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Currently investigating ERP system configuration changes necessary to report associate degree program length to NSLDS at two years. Name(s) of the contact person(s) responsible for corrective action: Nanci A. Beier, Registrar Planned completion date for corrective action plan: Spring 2024

View Audit 12444

Finding 9095 (2023-001)

Significant Deficiency 2023

Anne Arundel Community College

MD

Student Financial Aid Significant Deficiency Equipment & Real Property Management § 200.303

2023-001: Gramm-Leach-Bliley Act Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Condition: Certain elements of the College’s information security program were not maintained in written form. Recommendation: We recommend the College ensure its written informati...

2023-001: Gramm-Leach-Bliley Act Student Financial Aid Cluster – Assistance Listing No. 84.063, 84.268, 84.007, 84.033 Condition: Certain elements of the College’s information security program were not maintained in written form. Recommendation: We recommend the College ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to the conclusion of our audit the College documented in writing the required minimum elements. Name(s) of the contact person(s) responsible for corrective action: Dr. Richard C. Kralevich, Vice President, Information and Instructional Technology Planned completion date for corrective action plan: Completed

View Audit 12444

Finding 9094 (2023-001)

Significant Deficiency 2023

St. Clair County Housing Authority

IL

HUD Housing Programs Significant Deficiency Special Tests & Provisions

Finding 2023-001- Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Significant Deficiency Housing Choice Voucher Program CFDA #14.871 Corrective Action Plan: 1) SCCHA will continue increased monitoring and review of HCVP files to improve acc...

Finding 2023-001- Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Significant Deficiency Housing Choice Voucher Program CFDA #14.871 Corrective Action Plan: 1) SCCHA will continue increased monitoring and review of HCVP files to improve accuracy and ensure compliance with regulatory and statutory requirements related to income projection and tenant rent determinations. 2) SCCHA will continue to require any new staff members with income projection / rent calculation responsibilities to attend HCVP rent calculation training and pass the corresponding certification exam. 3) SCCHA will contract with an industry consultant to review internal processes and procedures related to income projections / tenant rent calculations specifically and initial eligibility and annual and interim recertifications processes in general to identify potential methods of improving accuracy and streamlining the process. Anticipated Completion Date: 1) June 30, 2024 2) June 30, 2024 3) April 30, 2024, depending on third-party trainer availability Persons Responsible: Larry McLean-Executive Director, Pam Jackson-HCV Program Director, Suellen Riley-Keen-Program Integrity & Compliance Coordinator

View Audit 12429

Finding 9065 (2023-003)

Significant Deficiency 2023

Edgar School District

WI

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

Elementary and Secondary School Emergency Relief Assistance Listing Nos. 84.425D and 84.425U Recommendation: CLA recommends that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no...

Elementary and Secondary School Emergency Relief Assistance Listing Nos. 84.425D and 84.425U Recommendation: CLA recommends that the District implement a formal review process over the reporting requirement relating to ESSER annual reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual ESSER reporting will be prepared by the bookkeeper, reviewed and signed off by the District Administrator, and be submitted Name(s) of the contact person(s) responsible for corrective action: Cari Guden, District Administrator Planned completion date for corrective action plan: July 1st 2023

View Audit 12412

Finding 9062 (2023-004)

Significant Deficiency 2023

Edgar School District

WI

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.214

Child Nutrition Cluster - Assistance Listing nos. 10.553 and 10.555 Recommendation: CLA recommends the District review and update policies and procedures over review of certain transactions to ensure that all federal grants with covered transaction have vendors reviewed for suspension and debarment ...

Child Nutrition Cluster - Assistance Listing nos. 10.553 and 10.555 Recommendation: CLA recommends the District review and update policies and procedures over review of certain transactions to ensure that all federal grants with covered transaction have vendors reviewed for suspension and debarment status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All food service vendors will be checked for suspension and debarment on the Sam.gov website. Name(s) of the contact person(s) responsible for corrective action: Morgan Mueller, Bookkeeper Planned completion date for corrective action plan: July 1st 2023

View Audit 12412

Finding 9059 (2023-001)

Significant Deficiency 2023

Dayton Early College Academy

OH

Subrecipient Monitoring Period of Performance Reporting § 200.302 § 200.328 § 200.344

Finding Number: 2023-001 Planned Corrective Action: The Dayton Early College Academy will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: 07/01/2023 Responsible Contact Person: Steven Hinshaw, Treasurer

View Audit 12390

Finding 9042 (2023-003)

Significant Deficiency 2023

The Wellbeing Initiative, Inc.

NE

Cash Management Internal Control / Segregation of Duties Reporting § 200.305

2023-003 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Cash Management Corrective Action Plan: Wellbeing Initiative has reviewed Title 2 CFR §200.305 and updated the Internal Controls Policy and Procedure Manual to include the following policy. Other polic...

2023-003 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Cash Management Corrective Action Plan: Wellbeing Initiative has reviewed Title 2 CFR §200.305 and updated the Internal Controls Policy and Procedure Manual to include the following policy. Other policies and procedures have been implemented and used since the incident to prevent the erroneous draw of funds prior to their expenditure. Item 10.3. Cash Management- : Criteria for cash management requirs non-Federal entities to utilize the reimbursement method and requires that expenditures were incurred prior to the date of the reimbursement request. Funds drawn from the Federal Payment Management System are deposited into a separate account and transferred to the appropriate account for reimbursement of previously accrued expenses. As allowable by grant guidelines the organization may drawdown funds in advance for expenditures to be made within the next 72 hours and meet the following requirements: i. Be limited to the minimum amounts needed to cover allowable project costs ii. Be timed in accordance with the actual immediate cash requirements of carrying out the approved project iii. Not be made to cover future expenditures Anticipated Completion Date: Completed 11/16/2023 Responsible: Chief Executive Team Danielle Smith and Sadie Thompson

View Audit 12371

Corrective Action Plans

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