Corrective Action Plans

Finding 4203 (2023-005)

Significant Deficiency 2023

AZ

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

Recommendation: Implement policies and procedures that ensure the indirect cost calculation is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organizatio...

Recommendation: Implement policies and procedures that ensure the indirect cost calculation is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures that ensure the indirect cost calculation is reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4202 (2023-004)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

Internal Control / Segregation of Duties Cash Management Significant Deficiency § 200.303

Recommendation: Implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organizat...

Recommendation: Implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures that ensure the cash management requirement is reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4201 (2023-003)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

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

Recommendation: Implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in ...

Recommendation: Implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4196 (2023-002)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

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

Recommendation: Implement policies and procedures that ensure the calculation of the matching requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to findin...

Recommendation: Implement policies and procedures that ensure the calculation of the matching requirement is reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures that ensure the calculation of the matching requirement is reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4195 (2023-001)

Significant Deficiency 2023

YWCA Metropolitan Phoenix

AZ

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

Recommendation: Implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in ...

Recommendation: Implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Explanation of disagreement with audit finding: Management agrees with the audit finding. Action planned/taken in response to finding: Organization will update and implement policies and procedures surrounding the cash disbursement process that ensures all disbursements are reviewed and approved by a second, independent individual. Name(s) of the contact person(s) responsible for corrective action: Debbie Esparza Planned completion date for corrective action plan: January 31, 2024

View Audit 6513

Finding 4027 (2023-006)

Significant Deficiency 2023

Shepherd Public School District

MI

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

Finding Number 2023-006 — Significant Deficiency in Internal Control — Covid 19-ESSER II 23b-Summer School and ESSER II-98C - Approval Process Condition: During expense testing of ESSER funds, a July 2022 expenditure for $24.95, payable to BMO, and an August 2022 invoice for $10,167, payable to IXL ...

Finding Number 2023-006 — Significant Deficiency in Internal Control — Covid 19-ESSER II 23b-Summer School and ESSER II-98C - Approval Process Condition: During expense testing of ESSER funds, a July 2022 expenditure for $24.95, payable to BMO, and an August 2022 invoice for $10,167, payable to IXL for math software licenses, were not approved by the Director of Business Services. During this time, the Director of Business Services position was vacant. Proper internal control procedures would ensure a proper approval process, for any position that is temporarily vacant. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: December 31, 2023 Corrective Action: Develop an approval process workflow that would temporarily utilize another administrator for approvals in Munis if any key position is vacant. The district has two administrators per building. The administrators will have the other building administrator act as approver for that building in the event an administrative position is vacant. If both principal positions are vacant, an administrator in another building will be integrated into the approval process for the building with no administrator. At Central Office, the next key position for approvals would be Trina Smith, the Accounts Payable/Accounts Receivable Accountant. If this position is vacant, the llRlPayroll Accountant will assume those approval duties. The final step of approval is the Director of Business Services to approve items before the AP/AR position can process any items. These items include invoices, requisitions, purchase orders, payroll related items and journal entries. In the event the Director of Business Services position is vacant, the District Superintendent of Schools will be the final approver. Sincerely, Carl Seiter Director of Business Services Shepherd Public Schools

View Audit 6347

Finding 3732 (2023-001)

Significant Deficiency 2023

America Can!

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Corrective Action Plan (Prepared by the Charter Holder) Finding 2023 – 001 Management has recognized the need for additional personnel to assist in ensuring compliance and accuracy with various reporting and compliance requirements. In September 2023, the Charter Holder posted a grant manager positi...

Corrective Action Plan (Prepared by the Charter Holder) Finding 2023 – 001 Management has recognized the need for additional personnel to assist in ensuring compliance and accuracy with various reporting and compliance requirements. In September 2023, the Charter Holder posted a grant manager position to support the Chief Financial Officer with state and federal reporting, budgeting, and grant compliance. While the position is vacant, the Charter Holder’s business manager is reviewing financial and compliance reports for accuracy. Management has reached out to Texas Education Agency about the reporting error and is waiting for further instructions on how to correct the reporting error. Responsible Party: Marian Hamlett, CFO Implementation Date: Immediately

View Audit 5886

Finding 3486 (2023-002)

Material Weakness 2023

Colorado Springs School District 11

CO

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

2023-002 Finding: Assessment System Security Title 1, Section 1111(b)(2)(B)(iii) of the ESEA (20 USC 6311(b)(2)(B)(iii))) Summary of Finding: The District is required to establish internal controls to ensure assessment security. Historically one of these internal controls included a Site Visit Sche...

2023-002 Finding: Assessment System Security Title 1, Section 1111(b)(2)(B)(iii) of the ESEA (20 USC 6311(b)(2)(B)(iii))) Summary of Finding: The District is required to establish internal controls to ensure assessment security. Historically one of these internal controls included a Site Visit Schedule to provide security assessment reviews. Site visits were performed at a select number of schools but did not include all Title schools in compliance with the requirements of the grant. Status: Corrective action in progress Client Planned Action: The District concurs with the recommendations and is currently implementing a process to ensure compliance. The Chief of Strategy and Data Acquisition has developed in coordination with the district Director of Metrics and Accountability, Area Superintendents, and the Colorado Department of Education Assessment Division a process processes to implement the needed internal controls that will ensure compliance to this requirement. They are as follows: Area Data Coaches will visit their portfolio of schools in the first 3 days of the state assessment window to ensure compliance with assessment security policies and procedures. Each data coach will receive full training from the CDE and the District Assessment Coordinator to ensure compliance with all security protocols in each building. Education Insights utilizes Area Data Coaches who work in close partnership with each Area Superintendent. Client Responsible Party: Natasha Crouse, Director of Metrics and Accountability. Each site visit will be documented with findings and any pertinent outcomes recorded. These logs will be securely stored on the Education Insights shared drive. Client Responsible Party: Dr. David Khaliqi, Chief of Strategy and Data Acquisition Completion Date: Assessment security training implemented as of March. 1, 2024. Standardized security assessment checklists and rubrics will be established by April 1, 2024. All site visits will be completed by April 10, 2024. Ongoing training throughout the year will be accomplished as needed. Adjustments and revisions to initial processes will be implemented as needed. Time and Effort certifications will be completed semi-annually.

View Audit 5457

Finding 3405 (2023-003)

Material Weakness 2023

Brodstone Memorial Hospital D/b/a Brodstone Healthcare and Affiliate

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management § 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. The Hospital claimed reimbursement for health-related lost revenue during the COVID-19 pandemic. Condition: The Hospital claimed reimbursement for health-related lost revenue based on a comparison of actual monthly revenue for the months of March, April, and May 2020 to the same corresponding months of 2019. Within the calculation, the Hospital excluded certain other operating revenue from the 2020 monthly totals which were included in the 2019 monthly totals. As a result, the compilation of revenue used between the periods was not consistently applied resulting in a higher lost revenue calculation than prescribed by the applicable guidance. Views of Responsible Officials: Management agrees with the finding. Planned Completion Date: April 30, 2024. Person Responsible: Cyrstal Wyatt, CFO.

View Audit 5310 Questioned Costs: $1

Finding 3404 (2023-001)

Significant Deficiency 2023

Alabama Hospital Association

AL

Cash Management Reporting Significant Deficiency § 200.302 § 200.303

Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited fo...

Corrective Action Plan: AlaHA will accomplish the following: 1) Send guidance to hospital systems with multiple facilities reported on their 941s that they should retain general ledger detail reconciliations to support the funds received. 2) Request the hospital involved in the exception cited for not having submitted general ledger evidence submit additional support for the reconciliation they submitted. 3) Should a similar tranche of funds become available in the future, AlaHA will ensure disbursements are not made before receipt of general ledger evidence to support the amount reported by the hospital. Target Date: For items 1 & 2 in the corrective action plan, November 6, 2023.

View Audit 5303

Finding 3168 (2023-002)

Significant Deficiency 2023

Hot Springs County School District #1

WY

Allowable Costs / Cost Principles § 200.303

2023-002 - Expenditure Controls - Significant Deficiency The District agrees that while significant progress has been made in this area, there is still work to do regarding the pre-authorization of purchases. The Business Manager has held meetings with each building and department individually to co...

2023-002 - Expenditure Controls - Significant Deficiency The District agrees that while significant progress has been made in this area, there is still work to do regarding the pre-authorization of purchases. The Business Manager has held meetings with each building and department individually to communicate proper procedures. She has also issued All Staff emails outlining these procedures and referencing board policy supporting these practices. Proper procurement procedure instructions are also available via video through a link on the Business Office Department page of the District website for reference. We recognize that proper training is imperative to compliance in all departments and the Business Office will continue to provide training throughout the year, with an emphasis in departments with new staff.

View Audit 5169

Finding 3132 (2023-003)

Significant Deficiency 2023

Delaware County Memorial Hospital D/b/a Regional Medical Center

IA

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Management agrees with the finding. The Medical Center’s secondary review control will ensure allowable expenses are being claimed.

View Audit 5069

Finding 3131 (2023-002)

Material Weakness 2023

Delaware County Memorial Hospital D/b/a Regional Medical Center

IA

Material Weakness Reporting Internal Control / Segregation of Duties § 200.303

Management agrees with the finding. Controls will be put into place to ensure the lost revenue calculation reported properly includes and excludes all relevant information.

View Audit 5069

Finding 3116 (2023-003)

Material Weakness 2023

Hastings College

NE

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

Finding 2023-003 Finding Title: Student Financial Assistance Cluster Name of Contact Person: Traci Boeve, Director of Financial Aid Corrective Action: Hastings College will add additional staff as a control to the current process. The Assistant Registrar and the Office of Financial Aid will be inclu...

Finding 2023-003 Finding Title: Student Financial Assistance Cluster Name of Contact Person: Traci Boeve, Director of Financial Aid Corrective Action: Hastings College will add additional staff as a control to the current process. The Assistant Registrar and the Office of Financial Aid will be included in the receipt of the graduation file. The Assistant Registrar will confirm in NSC (National Student Clearinghouse) the file was uploaded with no errors. The Office of Financial Aid will also request a report from NSLDS, which can be compared to the file that was directly uploaded to NSC. Anticipated Date of Completion: In place for 2023-2024 school year.

View Audit 5035

Finding 2747 (2023-001)

Significant Deficiency 2023

Town of Oakland, MD

MD

Procurement, Suspension & Debarment § 200.303

Correction Action to be Taken: Management will implement controls which ensure parties subject to this requirement are verified as not being present on the suspension and debarment list prior to initiating contracts or payments.

View Audit 4742

Finding 2676 (2023-003)

Significant Deficiency 2023

Lincoln County, Nebraska

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Lincoln County (submitting Department and County Clerk’s Office) will verify through Sam.Gov that all claims submitted for payment using federal funds are not suspended, debarred, or excluded from receiving federal dollars prior to payment of the claim.

View Audit 4513

Finding 2675 (2023-002)

None 2023

Lincoln County, Nebraska

NE

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

West Central NE Development District will need to collect reports from various offices (County Clerk & County Treasurer) to verify all expenditures and disbursements match and perform their own calculations.

View Audit 4513

Finding 2519 (2023-002)

Significant Deficiency 2023

C.h.i.l.d, Inc.

RI

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-002 Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management monitor reporting deadlines to meet all reporting requirements. Explanation of disagreement with audit finding: There is no...

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-002 Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management monitor reporting deadlines to meet all reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding, however, once again we plead considerable staff shortage. Action planned/taken in response to finding: We have now filled a critical position which will allow us to distribute responsibilities more effectively and ensure that internal controls are consistently applied. Name of the contact person responsible for corrective action: Anne Paglia Planned completion date for corrective action plan: December 2023. If the Department of Health and Human Services has questions regarding this plan, please call Anne Paglia at 401-732-5200

View Audit 4302

Finding 2492 (2023-001)

Significant Deficiency 2023

Three Square

NV

Special Tests & Provisions Reporting School Nutrition Programs § 200.303

2023-001 Internal Control Systems Over Special Tests and Provisions (Accountability for USDA Foods) – U.S. Department of Agriculture Food Distribution Cluster, Passed Through the State of Nevada Department of Agriculture Criteria: In accordance with 2 CFR 200.303(a), the auditee must maintain a sys...

2023-001 Internal Control Systems Over Special Tests and Provisions (Accountability for USDA Foods) – U.S. Department of Agriculture Food Distribution Cluster, Passed Through the State of Nevada Department of Agriculture Criteria: In accordance with 2 CFR 200.303(a), the auditee must maintain a system of internal controls to provide reasonable assurance that accurate and complete records are maintained with respect to the receipt, distribution, and inventory of USDA foods. Condition: Three Square’s internal controls, as designed, require an individual to verify that the weight of each product recorded in the inventory system is accurate. During inventory observation and testing audit procedures, twelve items were sampled. Of the twelve items, a discrepancy was discovered in the weight of one product when compared to the weight of the product recorded in the inventory system. Context: Of the twelve products selected for testing, the weight of one product was improperly recorded within Three Square’s inventory system. Cause: Internal controls over accountability for USDA foods were not operating effectively. Effect: Improper implementation of internal controls could result in improper tracking and reporting of costs of USDA foods. Recommendation: We recommend that management ensure that the system of internal controls over accountability for USDA foods is followed as designed. Views of Responsible Officials and Planned Corrective Actions: The weight of inventory is recorded within Three Square’s inventory management system as part of the receiving process. To ensure that all weight is properly recorded, Three Square will implement a verification process. Inventory control specialists, who are not part of the receiving process, will verify 10% of all items received weekly. This verification process will include independent weighing of items, and a review of the item description, quantity and dimensions recorded in the inventory management system. Any discrepancies will be reported to team leads to be rectified. Three Square is committed to ensuring that the system of internal controls is sufficient to ensure all records are accurate and complete.

View Audit 4240

Finding 2340 (2023-003)

Significant Deficiency 2023

Antelope County

NE

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

Antelope County will complete the annual expenditure report as required by ARPA Funding.

View Audit 4002

Finding 2339 (2023-002)

Significant Deficiency 2023

Antelope County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

It will be the practice of Antelope County to check vendor status with the SAMS/DUNS before any payments are made utilizing Federal funds. To further insure the funds are safely being utilized and spent, regular checks on the vendor status will be completed.

View Audit 4002

Finding 2325 (2023-003)

Significant Deficiency 2023

Holt County

NE

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

Holt County will create a spreadsheet that will track expenditures and obligations.

View Audit 3982

Finding 2324 (2023-002)

Significant Deficiency 2023

Holt County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Holt County's first choice will be to obtain a certificate or an agreement with each entity stating they are in good standing.

View Audit 3982

Finding 2250 (2023-001)

Significant Deficiency 2023

Public Broadcasting Service and Subsidiaries

VA

Subrecipient Monitoring Reporting § 200.303

The following action has been implemented to ensure that the required information is collected and reported timely in the FFATA Subaward Reporting System (FSRS). Beginning in the fiscal year 2024, the Company implemented a formal policy and procedure to file a FFATA sub-award report by the end of th...

The following action has been implemented to ensure that the required information is collected and reported timely in the FFATA Subaward Reporting System (FSRS). Beginning in the fiscal year 2024, the Company implemented a formal policy and procedure to file a FFATA sub-award report by the end of the month following the month in which they award any sub-grant or amendment equal to or greater than $30,000 in federal funds. The Company has completed and filed the required FFATA Subaward reporting for those sub-grants equal to or greater than $30,000 in federal funds and is current with the required reporting as of November 2023 and will monitor future sub-grants of federal funds in order to comply with the reporting requirements. Individual(s) Responsible for Corrective Action Plan Name: Meghan Biggs Position: VP & Controller Contact Number: (703) 739 7516 Anticipated Completion Date: November 2, 2023

View Audit 3886

Finding 2061 (2023-002)

Significant Deficiency 2023

Dakota County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, https://www .Sam.gov will be utilized to verify the entity has not been su...

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, https://www .Sam.gov will be utilized to verify the entity has not been suspended or debarred and such procedure will be adequately documented. Anticipated Completion Date: Ongoing Responsible Party:Dakota County Board of Commissioners: Robert J. Giese, Troy Launsby, Scott Love, Martin Hohenstein, and Brian VanBerkum.

View Audit 3571

Corrective Action Plans

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