Corrective Action Plans

Finding 381209 (2023-003)

Significant Deficiency 2023

UT

Period of Performance Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Summary: In connection with the audit procedures performed, it was noted that there was one expenditure amount that was incurred prior to the period of performance. Responsible Individuals: Christa Beauchat, Chief Financial Officer Corrective Action Plan: Management is revising its processes...

Finding Summary: In connection with the audit procedures performed, it was noted that there was one expenditure amount that was incurred prior to the period of performance. Responsible Individuals: Christa Beauchat, Chief Financial Officer Corrective Action Plan: Management is revising its processes to ensure that an adequate review of the period of performance is occurring over the expenditures of each federal award contract (verification that any expenditure charged to a federal award has actually been incurred during the federal award’s contract period). Anticipated Completion Date: Ongoing

View Audit 295925

Finding 381208 (2023-002)

Significant Deficiency 2023

Volunteers of America, Utah

UT

Procurement, Suspension & Debarment § 200.303 § 200.318

Finding Summary: In connection with the audit procedures performed, it was noted that the Organization did not adequately maintain complete procurement file documentation (as required by 2 CFR 200.318) related to one vendor that was selected for testing. Responsible Individuals: Christa Beauchat, Ch...

Finding Summary: In connection with the audit procedures performed, it was noted that the Organization did not adequately maintain complete procurement file documentation (as required by 2 CFR 200.318) related to one vendor that was selected for testing. Responsible Individuals: Christa Beauchat, Chief Financial Officer Corrective Action Plan: Management is implementing processes to maintain adequate and required documentation (under the CFR) for the selection of existing vendors and all vendors selected in the future to evidence adherence to general procurement standards and to evidence that vendors have been verified as not suspended or debarred. Specifically, management will maintain a vendor file (with required documentation) for any vendors that meet the criteria under the CFR. Anticipated Completion Date: Ongoing

View Audit 295925

Finding 381202 (2023-003)

Material Weakness 2023

Borden-Henryville School Corporation

IN

School Nutrition Programs Internal Control / Segregation of Duties Cash Management § 200.303

FINDING 2023-003 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program COVID-19 - National School Lunch Program Assistance Listings Numbers: 10.553, 10.555 Federal Award Numbers and Yea...

FINDING 2023-003 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program COVID-19 - National School Lunch Program Assistance Listings Numbers: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): SY22, SY23 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Eligibility, Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP), Special Tests and Provisions - Non-Profit School Food Service Accounts Audit Finding: Material Weakness Condition and Context The School Corporation had not established effective internal controls that would likely be effective in preventing, or detecting and correcting, noncompliance. Eligibility The School Corporation's policy is to have the Treasurer review and initial paper applications processed by the individual school treasurers to ensure that the eligibility determination was correct. However, six of the ten applications tested lacked documentation of this review. In addition, there was no internal control in place over applications submitted online. INDIANA STATE BOARD OF ACCOUNTS 18 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) The Treasurer performed the verification of free and reduced price applications without a documented review or oversight process in place to ensure that applications selected for verification were in compliance with requirements related to the program. Special Tests and Provisions - Non-Profit School Food Service Accounts The School Corporation did not have an internal control in place to ensure that reimbursements for meals served were properly credited to the School Lunch fund. The lack of internal controls for Eligibility and Special Tests and Provisions - Verification of Free and Reduced Price Applications (NSLP) was isolated to the second year of the audit period. The lack of internal controls over Special Tests and Provisions - School Food Accounts was systemic throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." Cause A proper system of internal controls was not designed by management of the School Corporation, which would include segregation of key functions. Embedded within a properly designed and implemented internal control system should be internal controls consisting of policies and procedures. Policies reflect the School Corporation's management statements of what should be done to effect internal controls, and procedures should consist of actions that would implement these policies. Effect Without the proper design or implementation of the components of a system of internal controls, including policies and procedures that provide segregation of duties and additional oversight as needed, the internal control system cannot be capable of effectively preventing, or detecting and correcting, material noncompliance. Questioned Costs There were no questioned costs identified. INDIANA STATE BOARD OF ACCOUNTS 19 BORDEN-HENRYVILLE SCHOOL CORPORATION SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Recommendation We recommended that management of the School Corporation design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

View Audit 295924

Finding 381194 (2023-002)

Material Weakness 2023

The Phalen Leadership Academy - Indiana, Inc.

MA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Special Tests and Provisions Education Stabilization Fund: Assistance Listing No. 84.425 Recommendation: We recommend that for future construction contracts financed by federal education funds PLA verify that subcontractors comply with prevailing wage requirements. Explanation of disagreement with a...

Special Tests and Provisions Education Stabilization Fund: Assistance Listing No. 84.425 Recommendation: We recommend that for future construction contracts financed by federal education funds PLA verify that subcontractors comply with prevailing wage requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: PLA will train operations and business office staff on the compliance requirements under Davis-Bacon to ensure construction contracts are entered into with qualified contractors and obtain and retain appropriate certified payroll documentation during the construction period. Name(s) of the contact person(s) responsible for corrective action: Carlo Hershberger, Director of Finance and Accounting; Javier Dimas, Vice-President of Operations; Martha Arellano, Procurement Manager and Buyer Planned completion date for corrective action plan: April 1, 2024 If the United States Department of Education has questions regarding this plan, please call Eva Spilker, Chief Financial Officer, at 410-598-3087.

View Audit 295918 Questioned Costs: $1

Finding 381193 (2023-006)

Significant Deficiency 2023

Hillcrest Family Services, INC

IA

Procurement, Suspension & Debarment § 200.303 § 200.318

Management states there was a procurement policy in place during this time but will now document that policy consistent with the federal laws and regulations.

View Audit 295917

Finding 381188 (2023-005)

Material Weakness 2023

Noblesville Schools

IN

Questioned Costs School Nutrition Programs Material Weakness § 200.303

FINDING 2023-005 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Req...

FINDING 2023-005 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Reporting compliance requirements. Context: During testing of reporting, we identified a control breakdown in the claim submission process. Although student meal data is summarized at the school level and reviewed by both the Food Services Bookkeeper and the Food Services Director, there is not a review of the actual claim submission prior to being submitted to the portal. Due to the breakdown in controls, we identified that the October 2022 revision claim overstated breakfasts served by 10 meals. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Director of Food Services will input the monthly claims into the state reporting system. This will be checked by the bookkeeper prior to submission to ensure data was entered correctly. Responsible Party and Timeline for Completion: Beginning January 2024

View Audit 295916 Questioned Costs: $1

Finding 381185 (2023-004)

Material Weakness 2023

Noblesville Schools

IN

School Nutrition Programs Eligibility Material Weakness § 200.303

FINDING 2023-004 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Req...

FINDING 2023-004 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Findings: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Eligibility compliance requirements. Context: During testing of eligibility, we noted that a formal documented control for the review of online student applications was not in place. Management indicated that the free and reduced parameters are updated annually in the Titan system, however, there was no documented review that the updated parameters were reviewed. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will document a formal review of student applications for free/reduced lunch. Management will also document a review over the thresholds for free/reduced meals within the Titan system to ensure they accurately input into the system this will be done by way of signature on the state published eligibility guidelines. This will be kept for record keeping. Responsible Party and Timeline for Completion: Beginning July 2024

View Audit 295916

Finding 381182 (2023-003)

Material Weakness 2023

Noblesville Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403

FINDING 2023-003 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Req...

FINDING 2023-003 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs Audit Findings: Material Weakness Condition: The School Corporation did not have adequate internal controls in place to ensure that the School Corporation complied with the allowable cost requirements. Context: During our testing of the School Corporation’s compliance with the allowable costs requirements for CNC, we noted the following exceptions in our testing of 120 disbursements (60 vendor and 60 payroll): 1. The School Corporation paid $233 of sales tax across three vendor food purchases. 2. For two employee payroll selections, we were unable to trace their rate of pay to a Board approved wage rate ordinance or contract. The total amount paid out to the two employees was $2,635. FINDING 2023-003 (Continued) 3. We identified one employee that the School Corporation incorrectly paid one hour more than what the timecard stated, resulting in an overpayment of $14. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Food Service Director will review and signature all fund 800 expenditures prior to disbursement. All Food Service employee wages will align with the board approved rates. Payroll will be signed as reviewed by direct supervisors and the Business Office prior to remittance. Responsible Party and Timeline for Completion: Implement immediately

View Audit 295916 Questioned Costs: $1

Finding 381179 (2023-002)

Material Weakness 2023

Noblesville Schools

IN

Allowable Costs / Cost Principles School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303 § 200.403

FINDING 2023-002 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Req...

FINDING 2023-002 Subject: Child Nutrition Cluster (CNC) – Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Allowable Costs Audit Findings: Material Weakness Condition: The School Corporation did not have adequate internal controls in place to ensure that the School Corporation complied with the allowable cost requirements. Context: During testing of vendor disbursements for the CNC program, we identified 9 disbursements in a sample of 60, for which there was no evidence of a formal documented review of the disbursement taking place prior to the disbursement. Additionally, during testing of CNC payroll disbursements, we selected 8 pay periods for controls testing and noted that none of the 8 pay periods had proof of a formal review of the payroll distribution prior to remittance. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Food Service Director will review and signature all fund 800 expenditures prior to disbursement. Payroll will be signed as reviewed by direct supervisors and the Business Office prior to remittance. Responsible Party and Timeline for Completion: Implement immediately

View Audit 295916

Finding 381157 (2023-003)

Significant Deficiency 2023

Catholic Charities, Archdiocese of San Antonio, Inc.

TX

Procurement, Suspension & Debarment Reporting Significant Deficiency § 200.303

Criteria: 2 CFR Section 200.303 of the Uniform Guidance requires the non-Federal entity to establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regul...

Criteria: 2 CFR Section 200.303 of the Uniform Guidance requires the non-Federal entity to establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. Condition: During testing of credit card purchases, we noted that supervisor approvals of expense reports were not timely obtained. Cause: Lack of timely review of credit card expense reports and transactions by supervisors for approval. Agency Response: Program directors/approvers of expense reports must go in by the 5th of the month after month end to approve/reject all employee expense reports assigned to them. The Financial Data Clerk will go in by the 6th of the month note the staff who has not approved their expense reports. The clerk will then communicate with the Director of Finance who in turn will send notification to the staff who is listed as approver. Once the staff is notified they will be given a 48 hour turn around to approve/reject, in the event they do not comply disciplinary action will be taken. After the 48 hours if report is not approved, Finance leadership will go into the system and review the report for approval or rejection. Responsible parties will be Alejandra Nunez, Financial Data Clerk and Lisette DeLeon, CFO, Cynthia Timm, Director of Finance, and Program designated expense report approvers. This will be implemented by February 2024.

View Audit 295879

Finding 381150 (2023-001)

Material Weakness 2023

Catholic Charities, Archdiocese of San Antonio, Inc.

TX

Reporting Internal Control / Segregation of Duties § 200.302 § 200.303

Criteria: 2 CFR Section 200.302 of the Uniform Guidance requires that a non-federal entity provide for accurate, Current, and complete disclosure of the financial results of each Federal award or program. Additionally, 2 CFR Section 200.303 of the Uniform Guidance requires the non-Federal entity to ...

Criteria: 2 CFR Section 200.302 of the Uniform Guidance requires that a non-federal entity provide for accurate, Current, and complete disclosure of the financial results of each Federal award or program. Additionally, 2 CFR Section 200.303 of the Uniform Guidance requires the non-Federal entity to establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations and the terms and conditions of the Federal award. Condition: Issues identified during our audit procedures over the SEFA and federal grant expenditure reports (SEFA project rollout). Cause: Lack of timely review and oversight of federal project expenditures, including the SEFA rollout report. In addition, the preliminary SEFA and underlying support was not timely reviewed by management after it was prepared by accounting staff. Agency Response: On a monthly basis there will be review on the expenditures to ensure that contractual expenses will be accrued. On a quarterly basis the SEFA rollout report will required to be created by the Financial Data Analyst or designee by the CFO. This report will be created by the 25th of the month after the quarter end. Once the report is created the analysis and review of expenditures to revenues will also occur. Based on the analysis, any discrepancies that are noted will be communicated with the Director of Finance. Those discrepancies will be corrected within 48 hours by the program accountants with the direction of the Director of Finance. In the event that the staff fails to make the corrections there will be disciplinary action. By the 30th of the month the report will be given to the CFO for review and approval. Responsible staff will be Lisette DeLeon, CFO, Cynthia Timm, Director of Finance, various staff, Program accountants, and Boubacar Traore, Financial Analyst. This process will begin January 2024 and be fully implemented by February 2024.

View Audit 295879

Finding 381148 (2023-004)

Material Weakness 2023

Pike County School Corporation

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2023-004 Finding Subject: Special Education Cluster (IDEA) - Earmarking Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Earmarking to ensure non-public school expenditures were appropriately identified and reported. Contact Person Re...

FINDING 2023-004 Finding Subject: Special Education Cluster (IDEA) - Earmarking Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Earmarking to ensure non-public school expenditures were appropriately identified and reported. Contact Person Responsible for Corrective Action Plan: Sara Harpenau Contact Phone Number and email Address: harpenaus@dspcoop.org, 812 482-6661 Views of Responsible Officials: We agree with the finding. Description of Corrective Action: The Finance Manager of the Exceptional Children’s Co-op has developed an Excel spreadsheet and workbook for each of the employees who are providing services to homeschooled children and the private school special education children. This spreadsheet enables them to document the children to whom they provide services, the dates of the services, the purpose of the encounter, and the duration of the visit. Each employee has a calculated goal of the time that is required of them throughout the school year to provide these services. Anticipated Completion Date: This method was implemented in the 2022/2023 school year and will continue with each school year as needed.

View Audit 295872

Finding 381142 (2023-003)

Material Weakness 2023

Pike County School Corporation

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.303 § 200.313

FINDING 2023-003 Finding Subject: COVID-19 Education Stabilization Fund-Equipment and Real Property Management Summary of Finding: There was no internal control procedure to ensure that a capital asset purchased with Federal money was listed in the asset ledger with the serial number or other identi...

FINDING 2023-003 Finding Subject: COVID-19 Education Stabilization Fund-Equipment and Real Property Management Summary of Finding: There was no internal control procedure to ensure that a capital asset purchased with Federal money was listed in the asset ledger with the serial number or other identification number, the source of funding for the property (including the federal award identification number), percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, and use and condition of the property. Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Corporation Treasurer or the Accounts Payable processor will make copies of any invoices over $5,000 and place them in a folder for addition to the asset listing. Those copies will also include what fund the item was paid from to properly note that Federal money was spent on that purchase. When Adtec performs the physical inventory and presents the listing, the Treasurer will verify that all items and necessary information have been included. Anticipated Completion Date: This is anticipated in being added to the asset ledger in August 2024.

View Audit 295872

Finding 381136 (2023-002)

Material Weakness 2023

Pike County School Corporation

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

FINDING 2023-002 Finding Subject: COVID-19 Education Stabilization Fund-Special Tests and Provisions-Wage Rate Requirement Summary of Finding: There was no internal control procedure to ensure that construction contracts paid from federal grant funds included a prevailing wage rate clause. This woul...

FINDING 2023-002 Finding Subject: COVID-19 Education Stabilization Fund-Special Tests and Provisions-Wage Rate Requirement Summary of Finding: There was no internal control procedure to ensure that construction contracts paid from federal grant funds included a prevailing wage rate clause. This would include a requirement to submit a copy of the payroll and statement of compliance to the entity for each week in which contract work was performed. Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The School Corporation will ensure when spending federal grant funds on contracted projects that a prevailing wage clause is included in the contract. The internal control policy will include that the Superintendent and Assistant Superintendent will verify the contract has the prevailing wage clause and that the contractor is submitting certified payrolls each week in which contract work is performed. Anticipated Completion Date: The amended contract has been approved with the vendor and funds will be spent by June 2024. Certified payrolls were requested March 5, 2024.

View Audit 295872

Finding 381133 (2023-004)

Material Weakness 2023

Helix Network of Educational Choices

LA

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

2023-004 Documentation of Approval and Review of Cash Disbursements Management Response: Management concurs with the recommendation above. Management will ensure internal controls are operating effectively and documentation of controls is maintained for a reasonable period of time, to at least inclu...

2023-004 Documentation of Approval and Review of Cash Disbursements Management Response: Management concurs with the recommendation above. Management will ensure internal controls are operating effectively and documentation of controls is maintained for a reasonable period of time, to at least include until the expiration of audit or other relevant compliance requirements. Since their inception, the Academies had outsourced its accounting function to an outside company. Management has now moved that function in-house and hired a full-time finance director to oversee all accounting functions. The finance director will be responsible for monitoring all financial policies and procedures. Responsible Person: Preston Castille, Jr., Helix Community Schools, President Anticipated Remediation Date: Fiscal year ended June 30, 2024

View Audit 295868

Finding 381125 (2023-004)

Material Weakness 2023

St Anthony Regional Hospital & Nursing Home

IA

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture & Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not maintain a res...

Federal Agency Name: Department of Agriculture & Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not maintain a reserve account or request the Department of Agriculture’s (USDA) permission prior to entering into new debt in compliance with their debt agreements. As of June 30, 2023, the Hospital should have USDA debt reserves at least equal to $417,954. Responsible Individuals: Eric Salmonson, CFO Corrective Action Plan: Management agrees with the finding. The Hospital has reviewed the internal controls and implemented improvements related to their USDA debt. They have also funded our USDA debt reserve account and worked with USDA to become compliant with all debt requirements. Anticipated Completion Date: March 5, 2024

View Audit 295863

Finding 381124 (2023-003)

Significant Deficiency 2023

St Anthony Regional Hospital & Nursing Home

IA

Allowable Costs / Cost Principles HUD Housing Programs Reporting § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Periods 4 & 5 TIN#420733472 Federal Financial Assistance Listing #93.498 Compliance Requirement: Allow...

Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Periods 4 & 5 TIN#420733472 Federal Financial Assistance Listing #93.498 Compliance Requirement: Allowable Cost/Cost Principles and Reporting Finding Summary: The Hospital did not have evidence of formal review and approval over tracking of expenditures and lost revenue calculation that were claimed for the program. The Hospital’s lost revenue calculation for Period 4 was also reported under Option II when it should have been reported under Option III. In addition, there was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420733472 was reviewed or approved by an individual separate from the preparer prior to submission. These errors were not noted during testing of the Phase 5 report. Responsible Individuals: Eric Salmonson, CFO Corrective Action Plan: Management agrees with the finding. The Hospital has reviewed the internal controls and implemented improvements related to allowability of all federal cost claimed, including those regarding the identification of duplicate items and approved costs. This was implemented prior to submitting the Phase 5 report. Anticipated Completion Date: September 5, 2023

View Audit 295863

Finding 381119 (2023-003)

Significant Deficiency 2023

Western Illinois University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Finding Number: 2023-002 - Inadequate Internal Control over Return of Title IV Funds Planned Corrective Action: The University agrees with the finding. The University has streamlined the process of R2T 4 to prevent delays in processing. This enhanced process creates a countdown report to prioritize ...

Finding Number: 2023-002 - Inadequate Internal Control over Return of Title IV Funds Planned Corrective Action: The University agrees with the finding. The University has streamlined the process of R2T 4 to prevent delays in processing. This enhanced process creates a countdown report to prioritize R2T4 calculation when staff resources as strained. Contact person responsible for corrective action: Roberta Smith Anticipated Completion Date: 06/30/2023

View Audit 295860

Finding 381111 (2023-002)

Material Weakness 2023

Western Illinois University

IL

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-002 - Inadequate Internal Control over Verification Requirements Planned Corrective Action: The University agrees with the finding. The Department of Education has removed the previously issued "suspension of verification," therefore internal controls and regular practices for ...

Finding Number: 2023-002 - Inadequate Internal Control over Verification Requirements Planned Corrective Action: The University agrees with the finding. The Department of Education has removed the previously issued "suspension of verification," therefore internal controls and regular practices for verification have been put back in place. Contact person responsible for corrective action: Roberta Smith Anticipated Completion Date: 06/30/2023

View Audit 295860

Finding 381106 (2023-001)

Material Weakness 2023

Western Illinois University

IL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-001 - Inadequate Internal Control over Student Enrollment Reporting Planned Corrective Action: The University agrees with the finding. The responsibility of reporting enrollment has been transitioned to a centralized office on campus. Internal controls have been put in place to...

Finding Number: 2023-001 - Inadequate Internal Control over Student Enrollment Reporting Planned Corrective Action: The University agrees with the finding. The responsibility of reporting enrollment has been transitioned to a centralized office on campus. Internal controls have been put in place to ensure enrollment is reported accurately/timely moving forward. Contact person responsible for corrective action: Roberta Smith Anticipated Completion Date: 06/30/2024

View Audit 295860

Finding 381067 (2023-006)

Material Weakness 2023

Greater Jasper Consolidated Schools

IN

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.303

Finding 2023-006 Finding Subject: Education Stabilization Fund-Equipment and Real Property Management and Reporting Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Equipment Management and Real Property Reporting.) Contact Person Respon...

Finding 2023-006 Finding Subject: Education Stabilization Fund-Equipment and Real Property Management and Reporting Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Equipment Management and Real Property Reporting.) Contact Person Responsible for Corrective Plan: Tina Fawks, Monica Young Contact Phone Number and Email Address: tfawks@gjcs.k12.in.us myoung@gjcs.k12.in.us 812-482-1801 Views of Responsible Officials: We agree with the Finding. Description of Corrective Plan: Equipment and Real Property: The School Corporation Treasurer will verify that the Assets updated by the third-party administrator will make sure the applicable federal guidelines are included on the asset schedule. Reporting: The Assistant Superintendent will prepare the Annual Report and the Treasurer will review the report prior to submission. Anticipation Completion Date: March 2024

View Audit 295824

Finding 381065 (2023-005)

Material Weakness 2023

Greater Jasper Consolidated Schools

IN

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.208 § 200.303 § 200.403

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) - Earmarking Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Earmarking. Contact Person Responsible for Corrective Action Plan: Sara Harpenau Contact Phone Number and emai...

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) - Earmarking Summary of Finding: The School Corporation had not properly designed or implemented internal controls over Earmarking. Contact Person Responsible for Corrective Action Plan: Sara Harpenau Contact Phone Number and email Address: harpenaus@dspcoop.org, 812 482-6661 Views of Responsible Officials: We agree with the finding. Description of Corrective Action: The Finance Manager of the Exceptional Children’s Co-op has developed an Excel spreadsheet and workbook for each of the employees who are providing services to the homeschooled children and the private school special education children. This spreadsheet enables them to document the children to whom they provide services, the dates of the services, the purpose of the encounter, and the duration of the visit. Each employee has a calculated goal of the time that is required of them throughout the school year to provide these services. Anticipated Completion Date: This method was implemented in the 2022/2023 school year and will continue with each school year as needed.

View Audit 295824

Finding 381059 (2023-004)

Material Weakness 2023

Greater Jasper Consolidated Schools

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

Finding 2023-004 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not properly designed or implemented internal controls over procurement and suspension and debarment Contact Person Responsible for Corrective Action: ...

Finding 2023-004 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not properly designed or implemented internal controls over procurement and suspension and debarment Contact Person Responsible for Corrective Action: Dr. Tracy Lorey, Monica Young, April Hopf Contact Phone Number and Email Address: tlorey@gjcs.k12.in.us myoung@gjcs.k12.in.us ahopf@gjcs.k12.in.us 812-482-1801 Views of Responsible Officials: We agree with the finding. Description of Corrective Action Plan: The school corporation will follow our Procurement policy in the future. Anticipation Completion Date: August 2024—Beginning of New School Year

View Audit 295824

Finding 381056 (2023-003)

Material Weakness 2023

Greater Jasper Consolidated Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2023-003 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: (suggestion: The School Corporation had not properly designed or implemented internal controls over eligibility.) Contact Person Responsible for Corrective Plan: Dr. Tracy Lorey, Monica Young, April Hopf Co...

Finding 2023-003 Finding Subject: Child Nutrition Cluster-Eligibility Summary of Finding: (suggestion: The School Corporation had not properly designed or implemented internal controls over eligibility.) Contact Person Responsible for Corrective Plan: Dr. Tracy Lorey, Monica Young, April Hopf Contact Phone Number and Email Address 812-482-1801 tlorey@gjcs.k12.in.us myoung@gjcs.k12.in.us ahopf@gjcs.k12.in.us Views of Responsible Officials: We agree with the Finding. Description of Corrective Action Plan: The corporation meets virtually each year with the software vendor to set up all free/reduced lunch applications, federal income guidelines and forms. A certified and signed copy of the income guidelines will be kept on file to show the match between the guidelines and point of sale. The applications that are flagged by the system will be reviewed for approval or denied and a copy will be maintained for The State Board of Accounts for audit. Anticipation Completion Date: February 2024

View Audit 295824

Finding 381041 (2023-005)

Material Weakness 2023

Winneshiek Medical Center

IA

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Medical Center’s lost revenue calculation did not take into considera...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: The Medical Center’s lost revenue calculation did not take into consideration budgeted 340B revenue, but included actual 340B revenue, and did not take into consideration Period 1 questioned costs that were replaced with excess lost revenue. In addition, the calculation was not reviewed and approved by a separate individual outside of the preparer. The Medical Center’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420680487 was not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Ben Stevens, CFO Corrective Action Plan: Management agrees with the finding. The Medical Center created a “Federal Reporting Review Policy” dated March 9, 2023 as a result of working with HRSA and the 2021FY audit. This policy was approved and is now in process. Anticipated Completion Date: No future reports are anticipated to be filed under this program.

View Audit 295813

Corrective Action Plans

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