Corrective Action Plans

Finding 567 (2023-001)

Significant Deficiency 2023

Covenant College, Inc. and Supporting Foundation

GA

Questioned Costs Subrecipient Monitoring Significant Deficiency

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1) Written Annual report to the Board of Directors on the overall status of ISP and GLBA compliance does not address risk management and control decisions, results of testing, security events or violations and management's respon...

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 1) Written Annual report to the Board of Directors on the overall status of ISP and GLBA compliance does not address risk management and control decisions, results of testing, security events or violations and management's response to each, and recommendations for changes in the Program. A report was submitted to the Board of Trustees in September 2023 for their review at the October meeting on campus. The Board will meet on campus again in March 2024 should any additional information or changes be needed. 2) MFA is not enabled for Banner by Ellucian and National Student Clearinghouse - § 314.4(c)(5) of the GLBA. This is in progress. Technical specifications for MFA in Banner have been reviewed. Testing of three possible options should be started in October 2023. Our Registrar has contacted the NSC and requested MFA on our accounts. 3) No annual penetration testing of information systems. This is in progress. As of September 2023 five vendors were being reviewed and evaluated for this engagement. 4) Vendors are only evaluated at contract initiation. This is in progress. Review of templates and approval needed has already started. Person Responsible for Corrective Action Plan: Dr. H. Collin Messer, Vice President for Academic Affairs Anticipated Date of Completion: May 1, 2024

View Audit 1114

Finding 558 (2023-001)

Significant Deficiency 2023

Augustana College

IL

Questioned Costs Subrecipient Monitoring Significant Deficiency

Department of Education Augustana College respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 to June 30, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistentl...

Department of Education Augustana College respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 to June 30, 2023 The findings from the 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 There were no financial statement findings in the current year. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 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: Augustana’s WISP will be revised to address GLBA required elements. Name of the contact person responsible for corrective action: Chris Vaughan Planned completion date for corrective action plan: January 1, 2024 If the United States Department of Education has questions regarding this schedule, please call Jacob Bobbitt at 309-794-7154.

View Audit 1111

Finding 466 (2023-001)

Significant Deficiency 2023

Global Learning Public Charter School

MA

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring

The Global Learning Charter Public School Administration and Board of Trustees acknowledge that the limitations present with the segregation of financial duties are the direct result of the size of the school’s financial operation. Over the next year, GLCPS will be undergoing a change in leadership ...

The Global Learning Charter Public School Administration and Board of Trustees acknowledge that the limitations present with the segregation of financial duties are the direct result of the size of the school’s financial operation. Over the next year, GLCPS will be undergoing a change in leadership that will provide the school with greater opportunity to enhance internal financial oversight, further augmenting existing procedures. GLCPS will continue evaluating these procedures and implementing changes as recommended. The Global Learning Charter Public School Foundation will also be reviewing the composition of its Board of Directors to clearly delineate the roles and responsibilities of its members.

View Audit 1016

Finding 435 (2023-001)

Significant Deficiency 2023

Northeast Ohio Medical University

OH

Subrecipient Monitoring Reporting Significant Deficiency

Finding Number: 2023-001 Anticipated Completion Date: October 16, 2023 Responsible Contact Person: Bianka Hernandez, Director of Grants Accounting Planned Corrective Action: All FFATA reporting will be entered onto the FSRS website immediately after full execution. The report will be saved and sub...

Finding Number: 2023-001 Anticipated Completion Date: October 16, 2023 Responsible Contact Person: Bianka Hernandez, Director of Grants Accounting Planned Corrective Action: All FFATA reporting will be entered onto the FSRS website immediately after full execution. The report will be saved and submitted monthly as new subaward agreements are fully executed. The FFATA report will be monitored and reviewed three business days before the end of the current month, so that the report may be submitted in a timely manner.

View Audit 953

Finding 434 (2023-001)

Significant Deficiency 2023

South Pointe Housing, Inc.

LA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

At the end of July, 2023, security deposits held on behalf of tenants were $9,206 and funds held in reserve at the bank were $9,442.80. August security deposits held on behalf of tenants were again $9,206 and funds held in reserve at the bank were $9,442.80. We will continue to monitor this on a mo...

At the end of July, 2023, security deposits held on behalf of tenants were $9,206 and funds held in reserve at the bank were $9,442.80. August security deposits held on behalf of tenants were again $9,206 and funds held in reserve at the bank were $9,442.80. We will continue to monitor this on a monthly basis.

View Audit 947

Finding 399 (2023-001)

Significant Deficiency 2023

Okemos Public Schools

MI

Questioned Costs Subrecipient Monitoring School Nutrition Programs

OKEMOS PUBLIC SCHOOLS FOR THE YEAR ENDED JUNE 30, 2023 Okemos Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Year ended June 30, 2023 District Con...

OKEMOS PUBLIC SCHOOLS FOR THE YEAR ENDED JUNE 30, 2023 Okemos Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period Year ended June 30, 2023 District Contact Person: Liz Lentz, Executive Director of Finance Finding 2023-001: Considered a significant deficiency in internal control over compliance. Recommendation: The District should consistently utilize a point-of-sale system to track and claim the number of meals served. Action to be Taken: Management agrees with the finding and had already changed procedures during the school year to better track and claim meals.

View Audit 830

Finding 372 (2023-001)

Material Weakness 2023

Kearney Housing Agency

NE

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

I have reached out to the Nebraskaland Bank regarding alternate collateralization. If this bank cannot provide appropriate collateral, a new banking institution will be found.

View Audit 782

Finding 367 (2023-001)

None 2023

Jessie Trice Community Health System, Inc.

FL

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

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implem...

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

View Audit 770

Finding 343 (2023-001)

None 2023

Southern Virginia University

VA

Student Financial Aid Subrecipient Monitoring Cash Management

Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: This finding affected a mere 2 of 40 records tested. Corrective action has been taken. The financial aid office has set up daily disbursement record submissions through its financial aid proce...

Name of Responsible Individual: Sarah Christoffersen, Interim Director of Financial Aid Corrective Action: This finding affected a mere 2 of 40 records tested. Corrective action has been taken. The financial aid office has set up daily disbursement record submissions through its financial aid processing system, Jenzabar Financial Aid, which will simplify the process and prevent reporting delays. Anticipated Completion Date: Completed

View Audit 719

Finding 338 (2023-002)

Significant Deficiency 2023

South Arkansas Regional Health Center, Inc.

AR

Cash Management Subrecipient Monitoring

The Center will be creating new general ledger accounts that reference the budget categories for the CCBHC grant. Each month there will be a reconciliation performed between the trial balance and amounts submitted to be drawn down for the grant. The expenses included in the general ledger will be re...

The Center will be creating new general ledger accounts that reference the budget categories for the CCBHC grant. Each month there will be a reconciliation performed between the trial balance and amounts submitted to be drawn down for the grant. The expenses included in the general ledger will be reviewed thoroughly to ensure they are allowable expenses. Additionally, all expenses will be coded to the account associated with the category they are budgeted in to allow for easier expense tracking when drawing down funds for the grant.

View Audit 683

Finding 323 (2023-001)

Significant Deficiency 2023

Mary Lee Flagship

TX

Questioned Costs Subrecipient Monitoring

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertif...

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases.

View Audit 626

Finding 236 (2023-003)

Significant Deficiency 2023

Sunrise Community Health

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement wi...

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization's enrollment and billing department will work together to identify when any errors occur based on the documentation the patient provides. The enrollment team will verify the rate, and the billing and coding team will begin checking to ensure the rate that the patient was screened for is the rate the patient is being charged for and that the correct discoutn applies.

View Audit 487

Finding 221 (2023-002)

Material Weakness 2023

Mary Lee Charles Place

TX

HUD Housing Programs Questioned Costs Subrecipient Monitoring

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertif...

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Estimated completion date is November 30, 2023.

View Audit 460

Finding 216 (2023-001)

None 2023

Chowan University

NC

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and docum...

Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and documentation process will be created to track, manage and reconcile the disbursement requests sent to COD. This process will aidin recognizing approved disbursements, rejected requests, and posting of disbursements. • The disbursement and reconciliation log will be reviewed by the Asst. Vice President for Student Financial Services as well as the Asst Vice President for Analytics & Audit. Anticipated Completion Date: The disbursement procedures will be monitored on an ongoing basis.

View Audit 409

Finding 209 (2023-001)

Significant Deficiency 2023

University of Health Sciences and Pharmacy in St Louis

MO

Student Financial Aid Subrecipient Monitoring Reporting

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the N...

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the National Student Clearinghouse's (NSC's) system automatically overrides the graduation data in the University's Jenzabar report without notifying the University, a two-step corrective action plan has been initiated. The modified reporting process to improve internal controls consists of the following steps: 1. Upload the initial Jenzabar enrollment reporting into the NSC system which will show full-time enrollment for both the bachelor's degree and the PharmD program; 2. File a second report reflecting the date of completion of the bachelor's degree for all students in the integrated program to remedy the NSC system override of graduation data in the initial Jenzabar report; and 3. Conduct a manual verification of graduation data in the National Student Loan Data System to ensure complete, accurate and timely reporting of graduation information from NSC. The modified reporting process is expected to be fully implemented at the conclusion of the 2023-2024 academic year in conjunction with completion of commencement, which is scheduled to occur in May 2024.

View Audit 398

Finding 87 (2023-001)

Significant Deficiency 2023

The Friendly House of Davenport, Iowa

IA

Subrecipient Monitoring

The Organization has implemented a facility monitoring program that incorporates all of the facility visit requirements as described in the grant agreement.

View Audit 105

Finding 1241199 (2022-002)

Material Weakness 2022

SIERRA SVING GRACE HMELESS PRJ

CA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Refer to the Attached Management's Formal Response and Corrective Action Plan.

View Audit 415297

Finding 1240748 (2022-002)

Material Weakness 2022

City of Milan

TN

Subrecipient Monitoring Reporting Material Weakness § 200.510 § 200.518

Inaccurate Grant Reporting (Material Weakness) Person Responsible for Implementing the Correction Plan: Autumn Stewart, City Recorder Anticipated Completion Date: June 30, 2026 Repeat Finding: No Planned Corrective Action: The City will strengthen internal controls over SEFA identification and prepa...

Inaccurate Grant Reporting (Material Weakness) Person Responsible for Implementing the Correction Plan: Autumn Stewart, City Recorder Anticipated Completion Date: June 30, 2026 Repeat Finding: No Planned Corrective Action: The City will strengthen internal controls over SEFA identification and preparation to ensure compliance with Uniform Guidance single-audit requirements. The City will also implement enhanced review and communication procedures with external auditors, as the condition was significantly impacted by deficiencies in the auditors’ evaluation and classification of major programs during the audit process.

View Audit 415132

Finding 1240203 (2022-004)

Material Weakness 2022

Ekentucky Advanced Manufacturing Institute INC

KY

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.339 § 200.501 § 200.512 § 200.520

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit an...

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

View Audit 414796

Finding 1239834 (2022-002)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document wi...

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document will name the individual accountable and the procedures needed to ensure compliance.

View Audit 414508

Finding 1235976 (2022-005)

Material Weakness 2022

Metro Area Continuum of Care for the Homeless

NE

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.512

Finding Reference Number 2022: Untimely Completion of the Single Audit Description of Finding: The Single Audit for the year ended December 31, 2022 was completed approximately three years after the fiscal year-end due primarily to prolonged delays in responses to audit requests and untimely submiss...

Finding Reference Number 2022: Untimely Completion of the Single Audit Description of Finding: The Single Audit for the year ended December 31, 2022 was completed approximately three years after the fiscal year-end due primarily to prolonged delays in responses to audit requests and untimely submission of required supporting documentation. Statement of Concurrence or Nonconcurrence: Threshold CoC concurs with the finding. Corrective Action: Management will establish formal procedures to ensure timely completion and submission of future Single Audits. Procedures will assign an audit coordinator, maintain a centralized tracking system for auditor requests and outstanding items, establish internal deadlines for providing requested documentation, and require regular progress communication with the audit team. Management will also ensure adequate staffing and resources are available throughout the audit process. Name of Contact Person: Jason Feldhaus, Executive Director, jason@thresholdcoc.org Projected Completion Date: December 31, 2026 Questioned Costs: None

View Audit 411573

Finding 1235975 (2022-004)

Material Weakness 2022

Metro Area Continuum of Care for the Homeless

NE

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Finding Reference Number 2022: Reporting Description of Finding: Management was unable to provide several required monthly and quarterly Emergency Rental Assistance Program reports requested during the audit and, for reports that were available, could not provide sufficient supporting documentation ...

Finding Reference Number 2022: Reporting Description of Finding: Management was unable to provide several required monthly and quarterly Emergency Rental Assistance Program reports requested during the audit and, for reports that were available, could not provide sufficient supporting documentation to substantiate certain reported amounts. Statement of Concurrence or Nonconcurrence: Threshold CoC concurs with the finding. Corrective Action: Management will strengthen controls over grant reporting by maintaining a reporting calendar with due dates and assigned owners; requiring completion, retention, and timely submission of all required monthly and quarterly reports; and retaining sufficient supporting documentation and reconciliations for all amounts reported to the grantor. A supervisory review will be documented before reports are submitted. This is similar to prior-year finding 2021-002. The corrective action above adds formal report tracking, retention, supporting documentation, and documented supervisory review to address the repeated issue. Name of Contact Person: Jason Feldhaus, Executive Director, jason@thresholdcoc.org Projected Completion Date: December 31, 2026 Questioned Costs: None.

View Audit 411573

Finding 1235934 (2022-002)

Material Weakness 2022

Southeastern Regional Medical Center

NC

Subrecipient Monitoring Cash Management Reporting § 200.512

2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 3...

2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 30, 2022, was not filed with the Federal Audit Clearinghouse on or before the deadline of March 31, 2023. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

View Audit 411536

Finding 1229758 (2022-006)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Reporting Subrecipient Monitoring Material Weakness

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: We recommend that management implement procedures to identify FFATA-reportable subawards and ensure all required reports are...

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: We recommend that management implement procedures to identify FFATA-reportable subawards and ensure all required reports are submitted timely. We further recommend that management review subawards issued subsequent to FY2022 to determine whether any required FFATA reports were omitted and consult with the applicable federal awarding agencies or pass-through entities regarding potential corrective actions, including whether late reporting may be accepted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has since submitted the missing FFATA reports and is implementing procedures to address the requirement going forward. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: July 23, 2026

View Audit 410987

Finding 1229757 (2022-005)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No.10.311 Recommendation: To implement policies, procedures, and trainings to ensure all subrecipient payment requests are reviewed and approved timely...

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No.10.311 Recommendation: To implement policies, procedures, and trainings to ensure all subrecipient payment requests are reviewed and approved timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a documented review and approval process for subrecipient payment requests. The grant manager will submit each subrecipient payment request to the Executive Director for review prior to payment. The Executive Director's approval will be documented via email, which will be retained along with the corresponding payment request as evidence of review. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026

View Audit 410987

Corrective Action Plans

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