Corrective Action Plans

Finding 8028 (2023-001)

Significant Deficiency 2023

Coldspring-Oakhurst Consolidated Independent School District

TX

Subrecipient Monitoring Equipment & Real Property Management Procurement, Suspension & Debarment

Corrective Action Plan The District will implement procedures to ensure planned capital expenditures, using Elementary and Secondary School Emergency Relief Funds, receive approval by either the U.S. Department of Education or the Texas Education Agency prior to the actual purchase. Person(s) Respon...

Corrective Action Plan The District will implement procedures to ensure planned capital expenditures, using Elementary and Secondary School Emergency Relief Funds, receive approval by either the U.S. Department of Education or the Texas Education Agency prior to the actual purchase. Person(s) Responsible Assistant Superintendent of Business & Finance Anticipated Completion Date Fiscal year 2023-2024

View Audit 10522

Finding 8008 (2023-001)

Significant Deficiency 2023

College of St Scholastica INC

MN

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the College review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the College review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: the College’s WISP will be revised to address GLBA required elements. Name of the contact person responsible for corrective action: Ben Deneen, Chief Information Officer Planned completion date for corrective action plan: January 31, 2024

View Audit 10482

Finding 8006 (2023-001)

Significant Deficiency 2023

Alabama Housing Finance Authority

AL

Questioned Costs Eligibility Significant Deficiency

Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and will provide additional tr...

Management agrees with the summarized findings. Management has reviewed the current policies and procedures to ensure that the steps to be performed are clearly stated for the underwriting and disbursement staff. Management has discussed the findings with staff members and will provide additional training as deemed necessary.

View Audit 10477 Questioned Costs: $1

Finding 7970 (2023-004)

Significant Deficiency 2023

Housing and Redevelopment Authority of Detroit Lakes

MN

HUD Housing Programs Special Tests & Provisions Significant Deficiency

2023-004 Contact Person Nichole Bristlin, Executive Director. Corrective Action Plan Management plans on reviewing control processes to ensure a second review is performed to determine that all appropriate documents are included in rent reasonableness calculations. Planned Completion Date for CAP...

2023-004 Contact Person Nichole Bristlin, Executive Director. Corrective Action Plan Management plans on reviewing control processes to ensure a second review is performed to determine that all appropriate documents are included in rent reasonableness calculations. Planned Completion Date for CAP Ongoing.

View Audit 10381

Finding 7969 (2023-003)

Significant Deficiency 2023

Housing and Redevelopment Authority of Detroit Lakes

MN

HUD Housing Programs Eligibility Significant Deficiency

2023-003 Contact Person Nichole Bristlin, Executive Director. Corrective Action Plan Management plans on reviewing control processes to ensure proper training of employees on calculating proper assistance to tenants receiving vouchers. Planned Completion Date for CAP Ongoing.

View Audit 10381

Finding 7958 (2023-001)

Significant Deficiency 2023

Liberty Grove Schools, Inc.

IN

Subrecipient Monitoring Procurement, Suspension & Debarment Significant Deficiency § 200.317 § 200.318 § 200.327

December 14, 2023 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 To Whom It May Concern, Liberty Grove Schools will take the following corrective action to address the FY2023 Single Audit Report finding: We will take corrective action to ensure our procurement policy is updat...

December 14, 2023 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 To Whom It May Concern, Liberty Grove Schools will take the following corrective action to address the FY2023 Single Audit Report finding: We will take corrective action to ensure our procurement policy is updated and in line with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements forFederal Awards (“Uniform Guidance”), specifically 2023-001. In addition, Morrise Harbour, Founder & Executive Director of Liberty Grove Schools, will ensure this updated procurement policy is implemented and approved by our Board of Directors. Sincerely, Morrise Harbour Founder & Executive Director

View Audit 10364

Finding 7954 (2023-001)

Significant Deficiency 2023

Hampshire College

MA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

U.S. Department of Education 2023-001 Student Financial Assistance Cluster – Assistance Listing Number: 84.007, 84.003, 84.038, 84.063, 84.268, 93.364 Recommendation: We recommend the College designate an individual to oversee the information security function and work to update the College’s writte...

U.S. Department of Education 2023-001 Student Financial Assistance Cluster – Assistance Listing Number: 84.007, 84.003, 84.038, 84.063, 84.268, 93.364 Recommendation: We recommend the College designate an individual to oversee the information security function and work to update the College’s written security program to ensure compliance with all standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College recognized the need to improve their security program and data governance, and this was a catalyst in their decision to outsource the management of their Information Technology functional area. On July 15, 2023, The College engaged Ellucian as its Information Technology partner. Ellucian will be working, along with management, to develop a security program for the College. The College will be establishing appropriate data governance and security protocols and controls as part of the overall security program. The College anticipates having a security program written, approved, and employed by June 30, 2024. Name(s) of the contact person(s) responsible for corrective action: Tana Boone, Vice President of Finance and Administration Planned completion date for corrective action plan: June 2024

View Audit 10363

Finding 7940 (2023-002)

Significant Deficiency 2023

Wake County, North Carolina

NC

Eligibility Significant Deficiency

Finding 2023-002 Significant Deficiency over Eligibility, repeat finding; Medicaid Cluster (Medicaid), Assistance Listing Number 93.778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendat...

Finding 2023-002 Significant Deficiency over Eligibility, repeat finding; Medicaid Cluster (Medicaid), Assistance Listing Number 93.778, U.S. Department of Health and Human Services, passed through the N.C Department of Health and Human Services (NCDHHS), Division of Medical Assistance. Recommendation: We recommend that the County train and monitor employees on the eligibility determination process. We also recommend the County review and amend current policies and procedures in place to ensure that all eligibility determination documentation is completed and retained by the County. Corrective Action Plan: The county will complete a quarterly review of errors in income, resources, and social security number and citizenship verification. For those staff identified by the targeted review with errors in these areas, supervisors will provide refresher training on Medicaid policy requirements. Additional targeted reviews will be completed monthly until the deficiencies are corrected. Proposed Completion Date: 1/31/2023 for initial quarterly review 2/28/2023 for refresher training for identified staff 7/31/2023 for additional reviews as needed for identified staff Contact Person: Yolanda McInnis, Economic Services Division Director

View Audit 10344

Finding 7900 (2023-004)

Significant Deficiency 2023

City of East Peoria, Illinois

IL

Procurement, Suspension & Debarment Significant Deficiency

Management will meet with the grant Program Manager(s) to review and ensure all of the City’s Federal Grants Management Policies are being adhered to.

View Audit 10301

Finding 7899 (2023-003)

Significant Deficiency 2023

City of East Peoria, Illinois

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management will meet with the grant Program Manager(s) to review and ensure all of the City’s Federal Grants Management Policies are being adhered to.

View Audit 10301

Finding 7882 (2023-002)

Significant Deficiency 2023

West Shore Community College

MI

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

2023-002 – Gramm Leach Bliley Missing Compliance Requirements. Auditor Description of Condition and Effect. The most recent written security policy fails to address how the College will oversee its information system service providers and the evaluation and adjustment of its information security pro...

2023-002 – Gramm Leach Bliley Missing Compliance Requirements. Auditor Description of Condition and Effect. The most recent written security policy fails to address how the College will oversee its information system service providers and the evaluation and adjustment of its information security program for any changes in the College's operations or the results of risk assessments. Additionally, the College's policy does not include performing annual penetration tests or biannual vulnerability assessments, as required by the Gramm Leach Bliley Act. 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 confirmed by a second individual. Corrective Action. To address the missing element of Gramm Leach Bliley #6, procedures will be set in place to ensure oversight of our information service providers. A team will review and track who our providers are ensuring they meet our technical requirements in addition to the needs of our students and staff. To address the missing element of Gramm Leach Bliley #7, procedures will be set in place to ensure oversight of our information security protocols. A team will review our procedures at least annually, and make any necessary adjustments as changes to security protocols continue to evolve. Part of the procedures will include mandatory semi-annual information security training required by all staff, in addition to basic security information provided annually to students. Finally procedures to perform annual penetration testing will be established based on relevant identified risks. This could include any vulnerability assessments, in the form of systematic scans or review of information systems reasonably identified. These assessments should be completed at a minimum semi-annually, or whenever there may be material changes in operations that could be impacted. Responsible Party. Director of Information Technology and Student Services. Anticipated Completion Date. January 1, 2024.

View Audit 10258

Finding 7878 (2023-001)

Significant Deficiency 2023

West Shore Community College

MI

Student Financial Aid Allowable Costs / Cost Principles Eligibility

2023-001 – Pell Grant Calculation. Auditor Description of Condition and Effect. The Uniform Guidance states that the College must determine the maximum scheduled award a student would receive based on their Expected Family Contribution (EFC) and Cost of Attendance (COA) using the payment schedule pr...

2023-001 – Pell Grant Calculation. Auditor Description of Condition and Effect. The Uniform Guidance states that the College must determine the maximum scheduled award a student would receive based on their Expected Family Contribution (EFC) and Cost of Attendance (COA) using the payment schedule provided by the U.S. Department of Education. Students must be awarded on the basis of a COA comprised of allowable costs assessed to all students carrying the same academic workload. COA must be prorated for students who are attending less than an academic year, or who are less than full-time in a term-based program. As a result of this condition, the College was exposed to an increased risk that incorrect information would be used to determine students' Pell Grant award amounts. Auditor Recommendation. We recommend the College implement procedures to ensure the COA and EFC used to calculate each student's Pell Grant is updated for each academic year and reviewed by an independent official. Corrective Action. In the spring of each year, the College Financial Aid Department will establish the Cost of Attendance (COA) necessary for Pell student eligibility, in addition to the Educational Financial Contribution (EFC) for the following fiscal year. Once these are calculated and established, the head of the Business Office will review the calculations, discuss, and approve. Once they have been approved, the appropriate information will be entered into the Financial Aid software system. Responsible Party. Director of Financial Aid and Head of the Business Office. Anticipated Completion Date. June 30, 2024.

View Audit 10258

Finding 7846 (2023-005)

Significant Deficiency 2023

City of Henderson

NV

Reporting Significant Deficiency

Finding 2023-005 Finding Summary: The City did not have adequate internal controls to ensure Project and Expenditures Reports were prepared in accordance with governing requirements as estimates obligations, rather than actual, were reported. The OMB Compliance Supplement requires that reports submi...

Finding 2023-005 Finding Summary: The City did not have adequate internal controls to ensure Project and Expenditures Reports were prepared in accordance with governing requirements as estimates obligations, rather than actual, were reported. The OMB Compliance Supplement requires that reports submitted to the federal awarding agency include all activity of the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with governing requirements. The City of Henderson (the City) must submit quarterly Project and Expenditure Reports that contain costs incurred during the covered period. Certain critical information includes: • Obligations and Expenditures • Current period obligation • Cumulative obligation • Current period expenditure • Cumulative expenditure Responsible Individuals: Rebecca Gillis, Accounting Manager Corrective Action Plan: City management and staff has reviewed the reporting requirements. The City has contacted the Treasury Department to assist in updating the obligated amounts reported in their reporting system. This is currently a system limitation that the City is unable to correct. Anticipated Completion Date: Ongoing pending response from the Treasury Department

View Audit 10194

Finding 7831 (2023-004)

Significant Deficiency 2023

Cherry County Hospital

NE

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Condition: The Hospital reported amounts in the reporting portal for information technology expenditures for Quarter 3 2022 in excess of amounts that are supported by audit evidence. Planned Corrective Action: Management will continue to refine processes to more diligently review the calculation of...

Condition: The Hospital reported amounts in the reporting portal for information technology expenditures for Quarter 3 2022 in excess of amounts that are supported by audit evidence. Planned Corrective Action: Management will continue to refine processes to more diligently review the calculation of allowable expenses and amounts entered into the provider relief fund reporting portal. Contact Person: Stephanie Jacobsen, Interim Chief Financial Officer Anticipated Completion Date: March 31, 2024

View Audit 10165

Finding 7805 (2023-004)

Significant Deficiency 2023

Town of Westport, Conencticut

CT

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

United States Department of the Education 2023-004 Special Education Cluster – AL No. 84.027/84.173 Recommendation: We recommend that the BOE policies be updated to include that vendors will be reviewed to ensure they are not suspended and debarred. Explanation of disagreement with audit finding...

United States Department of the Education 2023-004 Special Education Cluster – AL No. 84.027/84.173 Recommendation: We recommend that the BOE policies be updated to include that vendors will be reviewed to ensure they are not suspended and debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management further notes that a policy will be put in place to review all vendors through the Sam website to verify that the vendor has not been debarred or ineligible from receiving Federal Government funds. The of the contact person responsible for corrective action: Elio Longo Planned completion date for corrective action plan: June 30, 2024.

View Audit 10136

Finding 7804 (2023-002)

Significant Deficiency 2023

Town of Westport, Conencticut

CT

Procurement, Suspension & Debarment Reporting Significant Deficiency § 200.318 § 200.326

United States Department of the Education 2023-002 Special Education Cluster – AL No. 84.027/84.173 Recommendation: We recommend that the BOE review its formal procurement policies and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation...

United States Department of the Education 2023-002 Special Education Cluster – AL No. 84.027/84.173 Recommendation: We recommend that the BOE review its formal procurement policies and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management will update their purchasing policy to ensure compliance with Uniform Guidance. The of the contact person responsible for corrective action: Elio Longo

View Audit 10136

Finding 7802 (2023-003)

Significant Deficiency 2023

Town of Westport, Conencticut

CT

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

United States Department of the Treasury 2023-003 COVID-19 American Rescue Plan Act Local Fiscal Recovery – AL No. 21.027 United States Department of Transportation 2023-003 Highway Planning and Construction – AL No. 21.205 Recommendation: We recommend that the policies be updated to include t...

United States Department of the Treasury 2023-003 COVID-19 American Rescue Plan Act Local Fiscal Recovery – AL No. 21.027 United States Department of Transportation 2023-003 Highway Planning and Construction – AL No. 21.205 Recommendation: We recommend that the policies be updated to include that vendors will be reviewed to ensure they are not suspended and debarred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management further notes that a policy was put in place in March 2023 to review all vendors through the Sam website to verify that the vendor has not been debarred or ineligible from receiving Federal Government funds. Name of the contact person responsible for corrective action: Sheila Carey

View Audit 10136

Finding 7781 (2023-002)

Significant Deficiency 2023

Harry S. Truman Community Development Corporation

MO

Subrecipient Monitoring Significant Deficiency

2023-02 Recommendation: The Organization should review its transactions invoiced but not paid prior to year-end in order to properly record accrued liabilities. Corrective Action Planned: We acknowledge that there is currently not a sufficient process in place to ensure that accounts payable...

2023-02 Recommendation: The Organization should review its transactions invoiced but not paid prior to year-end in order to properly record accrued liabilities. Corrective Action Planned: We acknowledge that there is currently not a sufficient process in place to ensure that accounts payable and accrued expenses are properly recorded. A policy will be implemented to review the accounting records to ensure that accounts payable and accrued expenses are properly recorded now that the Organizations has staff and an outsourced accounting firm with the knowledge and skills to fulfill this need. Implementation Date: The entity will adopt a policy to review expenses invoiced but not yet paid to determine what amounts need to be accrued to ensure proper treatment of activity. This will be implemented by the entity by December 31, 2024.

View Audit 10117

Finding 7688 (2023-004)

Significant Deficiency 2023

School District of Random Lake

WI

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

There is no disagreement with the finding. District management is continuing to review policies and procedures in response to the finding.

View Audit 10028

Finding 7606 (2023-002)

Significant Deficiency 2023

Housing Authority of Billings, Montana

MT

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Housing and Urban Development CFDA #: 14-871 Housing Choice Voucher Program Applicable Federal Award Number and Year – 2023 Special Tests and Provisions Significant Deficiency in Internal Control over Compliance Finding Summary: HQS Enforcement there was 1 instance in which the la...

U.S. Department of Housing and Urban Development CFDA #: 14-871 Housing Choice Voucher Program Applicable Federal Award Number and Year – 2023 Special Tests and Provisions Significant Deficiency in Internal Control over Compliance Finding Summary: HQS Enforcement there was 1 instance in which the landlord didn’t correct the cited HQS deficiencies within the specified correction period and Housing Authority of Billings failed to abate the HAP timely. Responsible Individuals: Patti Webster, Chief Executive Officer / Executive Director and Helen Verhasselt, CFO Corrective Action Plan: Management agrees with the finding. The organization has completed retraining of staff and stressed the importance of following the Administrative Plan. The HCV Director is reviewing all HQS inspections monthly and conducts cross reference checks to ensure timely actions are taken on failed inspections. Anticipated Completion Date: December 20, 2023

View Audit 9948

Finding 7577 (2023-004)

Material Weakness 2023

Bethany Lutheran Home for the Aged, Inc.

SD

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookk...

Finding 2023-004 Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management created the reserve account of $114,600 in December 2022 which was established as a separate bookkeeping and bank account. However, management transposed the $116,400 amount that was required to be in the reserve account according to the Letter of Conditions. The Organization underfunded the actual reserve balance after interest earnings by $521 as of June 30, 2023. Additionally, the Organization withdrew $100,000 in May 2023 from the reserve account to deposit into the operating account and subsequently replenished the reserve account within 14 days without obtaining proper federal agency approval. Responsible Individuals: Dalton Huber, Chief Financial Officer Corrective Action Plan: A new line of credit has been established at First Interstate Bank to prevent this from reoccurring. The correct amount is presently in the reserve account. Anticipated Completion Date: 10/1/2023

View Audit 9917

Finding 7530 (2023-002)

Significant Deficiency 2023

Second Harvest Heartland

MN

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

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Scanning Applications: o Applications are physically filed by volunteers, th...

Audit Finding: ALN: 10.656 Grant No.: 204642 Grant Period: Year ended September 30, 2023 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action: • Scanning Applications: o Applications are physically filed by volunteers, then scanned into SharePoint and filed electronically. o SharePoint does not recognize hand-written applications, so we use a filing spreadsheet to track specific batch numbers for applications, which gives us the ability to trace an individual document. If the document is typed, then it can be recognized through a search in SharePoint.  Our SOP document for scanning applications can be found on the CSFP Sharepoint site. o We have two volunteers who are scanning on a weekly basis (between 150-250 applications scanned weekly), and we will continue to prioritize this project as more staff/volunteer hours become available. • If an application is missing: o Confirm that application information is in ClientTrack and document through a generated printed application. o Send application to distribution site for next distribution, to ensure participant signs new application before they receive another CSFP box. Anticipated Completion Date: We currently have two volunteers who are scanning on a weekly basis (between 150-250 applications scanned weekly), and we will continue to prioritize this project as more staff/volunteer hours become available. The current backlog is around one year with plans to get caught up using additional resources in the next few months.

View Audit 9830

Finding 7521 (2023-003)

Significant Deficiency 2023

Hays Medical Center, Inc.

KS

Reporting Significant Deficiency

Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Significant Deficiency; Reporting Compliance Requirement Corrective Action Plan: The Medical Center will strengthen procedures surrounding the reporting req...

Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Significant Deficiency; Reporting Compliance Requirement Corrective Action Plan: The Medical Center will strengthen procedures surrounding the reporting requirements related to Provider Relief Fund. The Medical Center will have a person independent of the reporting process review the reporting prior to submission. Anticipated Completion Date: The Medical Center intends to implement this immediately which will apply to any future reporting periods.

View Audit 9771

Finding 7519 (2023-001)

Significant Deficiency 2023

Hays Medical Center, Inc.

KS

Questioned Costs Cash Management Significant Deficiency

Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Noncompliance Finding/Significant Deficiency; Activities Allowed or Unallowed Compliance Requirement Corrective Action Plan: The Medical Center will impleme...

Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Noncompliance Finding/Significant Deficiency; Activities Allowed or Unallowed Compliance Requirement Corrective Action Plan: The Medical Center will implement procedures to ensure that future reporting of federal expenditures are reduced by an amount that other sources have reimbursed or are obligated to reimburse using actual Medicare cost report percentages to compute the amount that has been previously reimbursed by Medicare. Anticipated Completion Date: The Medical Center intends to implement this immediately which will apply to any future reporting periods.

View Audit 9771 Questioned Costs: $1

Finding 7514 (2023-006)

Significant Deficiency 2023

School District of Cadott Community

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Sue Shakal Anticipated Completion Date: Ongoing

View Audit 9733

Corrective Action Plans

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