Corrective Action Plans

Finding 58751 (2022-003)

Material Weakness 2022

IN

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.1 § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have com...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 565-5719 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The County will develop a policy and procedure to ensure we have complete and accurate information for the P & E report. In addition to the policy and procedure, an added person will assist with these reports by creating the reports through our financial software and reviewing before giving the reports to the Auditor who will prepare the P & E reports and then the Commissioner?s will review before the Auditor submits the report to the Treasury. The Bartholomew County Auditor?s Office is continually designing and implementing a proper system of internal controls so that any errors are detected and corrective measures are made as needed, Anticipated Completion Date: December 31, 2023

View Audit 55034

Finding 58750 (2022-002)

Material Weakness 2022

Bartholomew County

IN

Procurement, Suspension & Debarment § 200.214 § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 379-1510 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The Auditor?s Office will continue to work with the Commissioner?s O...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Pia O?Connor, Auditor Contact Phone Number: (812) 379-1510 Views of Responsible Official: I agree with the findings as stated Description of Corrective Action Plan: The Auditor?s Office will continue to work with the Commissioner?s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County will implement a Procurement, Suspension and Debarment Policy. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. The Auditor?s Office continues to work with the Commissioners to improve the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Funds. This includes, but is not limited to, internal controls and procurement, suspension and debarment processes. Anticipated Completion Date: Policy and Procedures will be implemented by December 31, 2023

View Audit 55034

Finding 58713 (2022-001)

Material Weakness 2022

Community Coordinated Child Care, Inc.

WI

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

CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Community Coordinated Child Care, Inc. (4-C) respectfully submits the following corrective action plan for the year ended December 31, 2022 Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, W...

CORRECTIVE ACTION PLAN Year Ended December 31, 2022 Community Coordinated Child Care, Inc. (4-C) respectfully submits the following corrective action plan for the year ended December 31, 2022 Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 2022 ? December 2022 The findings from the December 31, 2022, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS Finding 2022-001 During testing of allowable costs the following conditions were noted: ? The monthly cost allocation spreadsheets were not reviewed and approved to provide reasonable assurance that costs charged are allowable. ? 1 employee of 6 employees tested in a nonstatistical sample had time and effort that was not reviewed and approved to provide reasonable assurance that costs charged are allowable. Recommendation ? Cost allocation spreadsheets should be reviewed and approved monthly by the executive director to provide reasonable assurance that costs charged are allowable. ? Time and effort should be reviewed and approved to provide reasonable assurance that costs charged are allowable. ? Written procedures for allowable costs should be updated to include internal controls performed by the executive director and training should be provided to new personnel responsible for grant management. Action Taken DocuSign Envelope ID: ACAB2B66-E966-4B71-ADAC-68C66A23756D ? Cost allocation spreadsheets are now reviewed and approved monthly by the Executive Director. ? Time and effort for exempt employees are now reviewed and approved. ? Written procedures for payroll have been updated to include internal controls performed by the Executive Director. FEDERAL AWARD FINDINGS See finding 2022-001. If there are questions regarding this plan, please call Rebecca Strome, Business Manager, at 608-271-9181.

View Audit 56659

Finding 58707 (2022-004)

Material Weakness 2022

Jackson County, Florida

FL

Questioned Costs Period of Performance Subrecipient Monitoring § 200.303

FINDING 2022-004 COMMENT: Under Uniform Guidance requirements, the County may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that...

FINDING 2022-004 COMMENT: Under Uniform Guidance requirements, the County may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity. Each individual project under this program has a specified work deadline, which may be extended at the discretion of FEMA. RESPONSE: The County has requested an extension related to the FEMA work, but as of the date of the report, the extension has not been approved. Effective June 26, 2023, Rett Daniels, Deputy County Administrator, and Sarah Sun, Budget Director, will continue to seek and obtain the proper extensions needed for the FEMA project in question.

View Audit 56597 Questioned Costs: $1

Finding 58706 (2022-005)

Material Weakness 2022

Jackson County, Florida

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2021-003 COMMENT: Per the County's grant agreements with Florida Division of Emergency Management (FDEM), quarterly reports are required to be submitted through FloridaPA.com that include project costs and expenditures for each large project. Amounts in the quarterly reports should reconcile...

FINDING 2021-003 COMMENT: Per the County's grant agreements with Florida Division of Emergency Management (FDEM), quarterly reports are required to be submitted through FloridaPA.com that include project costs and expenditures for each large project. Amounts in the quarterly reports should reconcile to the County's accounting records and represent actual expenditures. The two large projects were tested for compliance with this requirement, including all quarterly reports submitted during the 2021 fiscal year for these projects. This was not a statistically valid sample. For all quarterly reports tested, the reported expenditures per quarter were unable to be reconciled to actual expenditures in the quarter per the invoices and other supporting documentation in the County's files. RESPONSE: Rett Daniels, Deputy Administrator, Sarah Suhn, Budget Director, and Tony Pumphrey, Finance Officer, will develop controls that will be effective July 31, 2023, to ensure quarterly reports submitted are reconciled to actual quarterly expenditures per invoices and other supporting documentation.

View Audit 56597

Finding 58686 (2022-001)

Material Weakness 2022

Jefferson County Department of Health

AL

Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.320

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED SEPTEMBER 30, 2022 The Jefferson County Department of Health submits the following corrective action plan for the year ended September 30, 2022: FINDINGS ? FEDERAL AWARDS: Audit Finding Reference 2022-001 Procurement Corrective Action Plan Rate quotes will...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED SEPTEMBER 30, 2022 The Jefferson County Department of Health submits the following corrective action plan for the year ended September 30, 2022: FINDINGS ? FEDERAL AWARDS: Audit Finding Reference 2022-001 Procurement Corrective Action Plan Rate quotes will be obtained from at least three (3) law firms as required for ?small purchases? by 2 C.F.R. 200.320. Person Responsible Rodney Holmes, Finance Director Estimated Completion Date May 31, 2023

View Audit 53878 Questioned Costs: $1

Finding 58628 (2022-002)

Material Weakness 2022

University of the Incarnate Word

TX

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319

Finding 2022-002 ? Procurement, Suspension, and Debarment Contact Person: Michael R. Castilleja, Director of Procurement & Other Support Services Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University did not main...

Finding 2022-002 ? Procurement, Suspension, and Debarment Contact Person: Michael R. Castilleja, Director of Procurement & Other Support Services Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University did not maintain records for procurements sufficient to detail the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Additionally, as required by the University?s Procurement and Bid Policy, the University did not maintain and provide documentation of the performance of an annual pricing review in order to assess whether preferred vendors continue to provide comparable pricing to other vendors. Identification of repeat finding: N/A UIW is committed to complying with the Procurement, Suspension, and Debarment regulations as indicated in the Uniform Guidance Procurement Standards (2 CFR ? 200.317 through 200.327). The University?s practice to maintain records for procurements which include the rationale for the method of procurement, selection of contract type, price analysis (including bidding process) and justification of vendor selection are currently being followed. Due to the urgency and state of emergency the University was under, it hindered our efforts of documenting our procurement practices. An oversight of the Procurement Standards has been reviewed and we are confident that our policies and procedures are sufficient to satisfy the requirements of the regulations. In addition, the University will implement a Sole Source/Preferred Vendor Form that will require justification and evidence of a vendor meeting the requirements of the purchase within a reasonable, allowable and consistent manner. ? Sole Source Vendors will be identified by department needs and may be requested at time of purchase requisition. Determination will be based on vendor availability of products and needs. ? Preferred Vendors will be maintained for the year and must be requested for market pricing review to include date of request, vendor category and price for like items. The Preferred Vendors list will be maintained in the Procurement Department and may be requested for review by initiator of purchase requisitions. All Sole Source/Preferred Vendor request should be reviewed/signed by requestor, a Procurement Officer, and the CFO & VP for Finance and Administration.

View Audit 56368

Finding 58625 (2022-001)

Material Weakness 2022

University of the Incarnate Word

TX

Student Financial Aid Eligibility Reporting § 200.303

Finding 2022-001 ? Special Tests and Provisions ? Enrollment Reporting (Student Financial Assistance Cluster) Contact Persons: Diana Dimas, Registrar?s Office Cristen Alecia, Office of Financial Assistance Current Status: Correction of this finding is in-progress. Anticipated Completion D...

Finding 2022-001 ? Special Tests and Provisions ? Enrollment Reporting (Student Financial Assistance Cluster) Contact Persons: Diana Dimas, Registrar?s Office Cristen Alecia, Office of Financial Assistance Current Status: Correction of this finding is in-progress. Anticipated Completion Date: December 31, 2023 Condition: The University of the Incarnate Word did not accurately or timely report student status changes to the NSLDS for 6 out of 60 students selected for testing. Identification of Repeat Finding: 2021-001, 2020-001, 2019-002 While the condition reported above is considered a repeat finding, it is important to note that the errors are different this year and that these findings are not a reflection of the university ignoring previous findings or failing to make changes, but rather a reflection of the complexity of enrollment reporting. There were no inaccurate or untimely attendance level changes, and the official withdrawals were reported accurately and timely. In this year?s errors, we had a student who graduated outside of a normal conferral date, causing them not to be reported during our normal degree conferral report to NSC. The Registrar?s Office is putting changes in place to either eliminate out-of-cycle conferrals, or increase the number of conferral and reporting dates to effectively capture all graduates. We know that only 6 students were caught up in this out-of-cycle graduation, as it was a specific exception for the School of Osteopathic Medicine, and is not a wide-spread issue. We had two unofficial withdrawals reported later than 60 days ? at 69 and 70 days. While the withdrawal and the changes were processed timely, the timing of the roster from NSLDS compared to the submission to NSC caused the report not to be acknowledged until after the 60 days had passed. The Office of Financial Assistance is researching the option of manually reporting unofficial withdrawals outside of the monthly reporting cycle in order to eliminate this problem. The Registrar?s Office will review the roster and NSC submission schedules to see if changes need to be made in order to better align reporting dates. We had three students inaccurately reported as withdrawn for the summer semester. These students were at least half-time in the preceding Spring and the following Fall, and therefore were not required to be reported as withdrawn. The Office of Financial Assistance and the Registrar?s Office will work together to research options in Banner and with NSC. It may be necessary to create a separate withdrawal code to identify summer withdrawals that should not be reported as withdrawn, and create a report to monitor the fall enrollment for these students in case they later withdraw from Fall and transition to a withdrawal which must be reported. The Banner system alone does not allow for the complicated logic mandated for summer reporting in the NSLDS Enrollment Reporting Guide. Our offices will continue to work in partnership to resolve these enrollment reporting issues. Cristen Alicea Director Office of Financial Assistance 210.805.1238 gimenez@uiwtx.ed www.uiw.edu/finaid Diana Dimas Associate Registrar Registration and Technology Office of the Registrar 210.832.5484 dimasd@uiwtx.edu www.uiw.edu

View Audit 56368

Finding 58620 (2022-004)

Material Weakness 2022

Tippecanoe School Corporation

IN

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

FINDING 2022-004 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-004 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding earmarking within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: Summer 2023.

View Audit 56365

Finding 58619 (2022-003)

Material Weakness 2022

Tippecanoe School Corporation

IN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding suspension and debarment within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58618 (2022-002)

Material Weakness 2022

Tippecanoe School Corporation

IN

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regard...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Amanda M. Brackett, Chief Financial Officer Contact Phone Number: (765) 269-8218 Views of Responsible Official: We agree with the findings identified. Description of Corrective Action Plan: In order to mitigate future findings regarding activities allowed and allowable costs within the Greater Lafayette Area Special Services cooperative, the TSC will implement procedures to ensure better internal controls which includes monitoring. The Chief Financial Officer will monitor the progress of the Corrective Action Plan to ensure that we fulfill our requirements of the CAP. Anticipated Completion Date: July 2021. Completion of this has been remedied an only affected year 1 of the audit period.

View Audit 56365

Finding 58547 (2022-003)

Material Weakness 2022

Sicangu Oyate Ho, INC

SD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The o...

2022-003 Payroll (Material Weakness) New Finding This Year Recommendation: Management should restrict payroll module access to those with a logical need for such access. Action Taken: St. Francis Indian School has checks and balances in place when changes need to be made in the payroll module. The only employees who have access are those who need to input data and make changes such as Human Resources and of course Payroll.

View Audit 55377

Finding 58540 (2022-002)

Material Weakness 2022

Frankton Lapel Community School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, Frankton-Lapel Schools will no longer plan on entering into a ...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Candace McDonald Contact Phone Number: 765-734-1261 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Going forward, Frankton-Lapel Schools will no longer plan on entering into a construction project through the Education Stabilization Fund. Anticipated Completion Date: Already completed.

View Audit 50226

Finding 58486 (2022-007)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option I to calculate lost revenue for its subsidiary, which consists of reporting quarterly net revenue by payor during the period of availability. Net revenue was determined by projecting payor deductions instead of using actual deductions as required by the terms and conditions of the award. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58485 (2022-006)

Material Weakness 2022

Regional West Health Services

NE

Reporting Internal Control / Segregation of Duties § 200.303

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the feder...

Material Weakness: Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: RWHS selected option II to calculate lost revenue for its subsidiary, which consists of a comparison of actual results during the period of availability to the approved budget in 2020 and 2021. The budget was required to be approved by March 27, 2020. The budget used for 2021 and 2022 was not approved by the required date. Planned Corrective Action: Management will refine processes to more diligently review the lost revenue calculation to ensure such amounts are in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: Ongoing

View Audit 54656

Finding 58476 (2022-003)

Significant Deficiency 2022

Mt. Graham Regional Medical Center, Inc.

AZ

Allowable Costs / Cost Principles Significant Deficiency § 200.303

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agre...

Finding 2022-003 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The Medical Center's eligible expenses listing had errors when agreed to underlying supporting documentation. Responsible Individuals: Kathleen Williams, Chief Financial Officer Corrective Action Plan: We will implement new control process which ensures amounts reported are reviewed and accurately reported. Anticipated Completion Date: September 27, 2023

View Audit 55247

Finding 58453 (2022-003)

Material Weakness 2022

North Spencer County School Corporation

IN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree t...

FINDING 2022-003 Contact Person Responsible for Corrective Action: Gerri Ford Contact Phone Number: 812-937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation Treasurer will prepare the annual reports and ensure the amounts agree to the accounting records. The annual reports prepared by the Corporation Treasurer will be provided to the Director of Learning who oversees the Elementary and Secondary School Emergency Relief (ESSER) grant to review and approve the amounts reported are accurate. After review and approval from the Director of Learning, the annual reports will be submitted by the Corporation Treasurer. Anticipated Completion Date: May 2023

View Audit 54408

Finding 58451 (2022-002)

Material Weakness 2022

North Spencer County School Corporation

IN

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

FINDING 2022-002 Contact Person Responsible for Corrective Action: Dan Scherry Contact Phone Number: (812) 937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At each Co-Op Board Meeting, the Superintendent will request a copy of the reimbursem...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Dan Scherry Contact Phone Number: (812) 937-2400 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: At each Co-Op Board Meeting, the Superintendent will request a copy of the reimbursement requests submitted indicating the amount in North Spencer?s non-public expenditures along with the supporting documentation (timesheets showing time spent with non-public students). Superintendent will make sure the two (requests and timesheets) agree in order to ensure a percentage is not used for the reimbursement requests. Anticipated Completion Date: March 15, 2023

View Audit 54408

Finding 58448 (2022-002)

Significant Deficiency 2022

Cleveland Area Hospital Trust

OK

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses re...

Consideration of Amounts Reimbursed from Other Sources Finding 2022-002 Federal Agency Name Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution/Federal Financial Assistance Listing #93.498 Finding Summary: The expenses reported as eligible for the American Rescue Plan (ARP) Rural Distribution were overstated. The error related to not identifying expenses that were reimbursement from other sources. Responsible Individuals: Ray Moss CFO Corrective Action Plan: We will implement an additional layer of review as part of the response of the findings above. Anticipated Completion Date: September 27, 2023

View Audit 55720

Finding 58441 (2022-101)

Significant Deficiency 2022

B J Enterprises, Inc.

AZ

Procurement, Suspension & Debarment Cash Management Eligibility § 200.303

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBE...

B J ENTERPRISES, INC. CORRECTIVE ACTION PLAN SEPTEMBER 30, 2022 REFERENCE: 2022-101 REPEAT FINDING REFERENCE: 2021-001 CFDA NUMBER: 10.558 ? CHILD AND ADULT CARE FOOD PROGRAM U.S. DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION - 2022 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER 6AZ300003 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Katie O'Neill, Director 2. Corrective action planned: a. For 2 of 40 providers files tested, menus were clerically inaccurate and did not support the meals claimed. The Area Coordinators will be retrained to double check their meal counting on their menus at least once before they submit their meal counts and one time after they submit their meal counts. See BJ Enterprises Procedures for Reading Menus, Section D, #6. b. For 1 of 40 provider files tested, meals were claimed for the provider's own child, when the provider was not eligible for free/reduced price meals. The menu reader must use the most current "Claiming Own" report while they are menu reading. The income applications have to be approved by the Assistant Director or Director prior to the menus being read. The menu reader will use this list, as well as the Master List when reading the menus. The Area Coordinators will be retrained to ensure that the provider who is claiming their own children qualify to do so. See BJ Enterprises Procedures for Reading Menus, Section C, #5. c. For 2 of 40 provider files tested meals were claimed when the provider's children were the only children present. This occurred when the day care children were disallowed. The Area Coordinators will be re-trained to disallow the day care providers own children when meals are disallowed for all of the day care children. See BJ Enterprises Procedures for Reading Menus, Section C, #5. d. For 1 of 40 provider files tested, meals were claimed outside of the current claim month. The Area Coordinators will be re-trained to disallow meals on the front end or the back end of the month. See BJ Enterprises Procedures for Reading Menus, Section B, #2. e. For 1 of 40 provider files tested, meals were claimed when the child was not indicated as being present for the meal. The times in and out were not on the day that was claimed. The Area Coordinators will be re-trained to disallow meals when the time in and outs are not written on the menu. See 8 J Enterprises Procedures for Reading Menus, Section C, #4. f. For 1 of 40 provider files tested, meals were claimed when no menu components were listed on the menu. The Area Coordinators will be re-trained to disallow meals when thy have no components listed on the menu. See BJ Enterprises Procedures for Reading Menus, Section B, #3. All of the menu mistakes were on paper menus. We are encouraging everyone to start claiming on computerized menus (KidKare) because there are less or no mistakes on those menus. 3. Anticipated completion date: June 30, 2023

View Audit 55181

Finding 58424 (2022-001)

Significant Deficiency 2022

Carroll Community College

MD

Eligibility Reporting Matching / Level of Effort / Earmarking § 200.303

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spendin...

Action taken in response to finding: After management was re-notified of the reporting errors in the HEERF reports on the college website, management has decided to completely reorganize the college webpage for HEERF reports. This will allow management and the reader to better understand the spending history of institutional and student portions of these grants. When the website is reorganized, quarterly reports will be reviewed and verified that student data is verified and reported correctly in the narrative of the reports. Name(s) of the contact person(s) responsible for corrective action: Ms. Karen Pelton, Mr. Timothy League and Mr. John Gay. Planned completion date for corrective action plan: Adjustments to the website and the review and correction of these reports, if needed, is currently in process and is expected to be completed no later than January 31, 2023.

View Audit 56029

Finding 58321 (2022-001)

Significant Deficiency 2022

Herzing University, Ltd.

WI

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

FY 2022 SFA Audit Corrective Action Plan Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2022 ? 12/31/2022 Comments on Findings and Recommendations: Finding 2022-001 ? Error in Reporting for NSLDS Finding: Herzing University did not properly report the studen...

FY 2022 SFA Audit Corrective Action Plan Audit Firm: RSM US LLP 30 S Wacker Drive, Suite 3300 Chicago, IL 60606 Audit Period: 1/1/2022 ? 12/31/2022 Comments on Findings and Recommendations: Finding 2022-001 ? Error in Reporting for NSLDS Finding: Herzing University did not properly report the student enrollment change for a student who received federal student aid to the National Student Loan Data System (NSLDS). Condition: The University did not report a student?s Program-Level or Campus-Level enrollment status change to NSLDS. Out of the 60 students tested, we noted 1 student (1.7%) whose status change at the Program-Level and Campus-Level was not reported to NSLDS. Action Taken: In this instance, the student identified was withdrawn from the University and was correctly reported to NSLDS as such through our standard enrollment reporting processes. The student then subsequently re-enrolled at the University in the subsequent academic period becoming an Active student, and then withdrew again prior to our next standard enrollment reporting process occurring (one month after the previously reported withdrawn status). At the point of the second standard enrollment reporting timeframe, the student status was once again withdrawn, therefore an update did not occur to their enrollment status. Our process did not have a mechanism to identify the student changing statuses in between those reporting periods so that the active enrollment status was reported and then changed back to withdrawn versus simply staying at a withdrawn status. In August 2022, Herzing University updated our enrollment reporting policy to send in enrollment reporting biweekly instead of monthly. This was done to ensure that each student?s enrollment status was accurately reported as soon as possible and to prevent issues that occur from delays in proper enrollment statuses being reported to NSLDS. This update inherently decreased the likelihood that status timing issues would occur given the condensed timeframe for reporting. In addition, as of May 1st, 2023 Herzing University has developed and implemented an exception reporting process that will identify any student that has status updates that occur but reverts back to the original status within the timeframe of the two enrollment reporting periods. Using the student identified in this finding as an example, if the student is at a withdrawn status at the first enrollment reporting period, then moves to an active status immediately after that but then withdraws again within that 2 week window and therefore goes back to a withdrawn status in the subsequent enrollment reporting period, while our standard reporting would still show the student withdrawn for both standard enrollment reporting timeframes, the exception report will flag that student for review since a status change occurred in between the two withdrawn statuses being reported out. Upon review of the exception report, all relevant status progressions will be correctly reported to NSLDS. The required corrective action for Finding 2022-001 listed in the SFA audit for the period 1/1/2022 ? 12/31/2022 was completed on 5/1/2023. The person responsible for completion of the corrective action was Kevin McShane, Vice President of Financial Aid & Compliance.

View Audit 55185

Finding 58295 (2022-001)

Significant Deficiency 2022

Saint Leo University, INC

FL

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate act...

2022-001 HEERF Reporting Recommendation: We recommend that the University review their reporting policies and procedures to ensure accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate action was taken to update the quarterly report and post the updated report to our university?s website. Error was made due to data file showing category under other uses in previous quarterly reports. When new quarterly report was prepared the amount was reported on proper lost revenue line but was not deducted from the other uses total. This resulted in an overstatement of expenditures. An additional step was implemented to confirm total balance with data spreadsheet balance of expenditures. Name(s) of the contact person(s) responsible for corrective action: Jennifer Martell, Controller Planned completion date for corrective action plan: This was immediately corrected when brought to our attention on 5/26/22 for the quarterly report ending 3/31/22 which was originally posted to our website on 4/10/22.

View Audit 60987

Finding 58233 (2022-003)

Significant Deficiency 2022

City of Omro

WI

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties...

Finding 2022-003 Condition One of the two reports selected for testing were not independently reviewed before submission. The sample is not statistically valid. Corrective Action Plan Corrective Action Planned: The City does not currently have sufficient staffing to provide segregation of duties in all areas. Upon start of employment of a new City Administrator/Treasurer on October 9, 2023, that position employee will be reviewing such reports and financial documents on a regular basis as part of his job duties. Name of Contact Person Responsible for Corrective Action: Barbara J. Van Clake, City Clerk/Deputy Treasurer. Anticipated Completion Date: October 2023.

View Audit 50354

Finding 58120 (2022-006)

Material Weakness 2022

County of San Joaquin

CA

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319 § 200.320 § 200.323

Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) CFDA No.: 93.323 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award Year: 2021-2022 Compliance Requirement: Procurement and Suspension and De...

Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) CFDA No.: 93.323 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award Year: 2021-2022 Compliance Requirement: Procurement and Suspension and Debarment Grant Award Number: COVID-19 ELC39 and COVID-19 ELC97 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-09. Management?s or Department?s Response: We Concur. Views of Responsible Officials and Corrective Action: Procedures have been developed and implemented to comply with the County?s policies over procurement and suspension and debarment. Name of Responsible Person: Bruce Cosby Name of Department Contact: Bruce Cosby Projected Implementation Date: July 1, 2023

View Audit 53495

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