Corrective Action Plans

Finding 1168645 (2025-001)

Material Weakness 2025

IN

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2025-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls over Eligibility Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Number...

FINDING 2025-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls over Eligibility Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2024, FY2025 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal, documented review control in place. There is no documented, secondary review for the applications entered in the food service software which determines eligibility. Additionally, there was no documented review by School Corporation personnel of the Income Eligibility Guidelines used by the food service software which are updated on annual basis Contact Person Responsible for Corrective Action: Amber Swinehart, Food Services Director Contact Phone Number: 765-759-2592 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Services Director will provide evidence of review for the eligibility parameters from Titan at least once a year prior to the start of the school year Anticipated Completion Date: 6/30/2026

View Audit 380596

Finding 1168615 (2025-001)

Material Weakness 2025

Independent School District #194

MN

Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.326

Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend that the District review its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the proc...

Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend that the District review its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so it is clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Bill Holmgren Planned completion date for corrective action plan: June 30, 2026

View Audit 380547

Finding 1168589 (2025-006)

Material Weakness 2025

City of Detroit, Michigan

MI

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

Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the program...

Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the programs in a manner that did not align with the allocation methodology outlined in the 2022–2023 cost allocation plan submitted to MDHHS. Furthermore, the plan lacked explicit certification and contained minor errors and omissions. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Regina Greear Terri Daniels Anticipated completion date: July 2026 Planned Corrective Action: Upon identification, the City worked with the Michigan Department of Health and Human Services (MDHHS) and obtained approval and acceptance of the indirect cost calculation. The City will continue to work with MDHHS to ensure full compliance. The City has initiated a review of its indirect cost allocation methodology to ensure compliance. Management is updating the cost allocation calculation to document the approved allocation method and ensure the method is in accordance with the approved plan. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements.

View Audit 380442

Finding 1168587 (2025-005)

Material Weakness 2025

City of Detroit, Michigan

MI

Subrecipient Monitoring Cash Management Material Weakness § 200.303 § 200.305

Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specif...

Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specifically for payments made to subrecipients. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Denise Fair Razo Regina Greear Terri Daniels Anticipated completion date: March 2026 Planned Corrective Action: The three payments made were paid one to two days after the 30 day reimbursement requirement. The City will review its subrecipient payment terms and implement additional processes to help ensure compliance with federal payment requirements.

View Audit 380442

Finding 1168586 (2025-004)

Material Weakness 2025

City of Detroit, Michigan

MI

Internal Control / Segregation of Duties Eligibility Subrecipient Monitoring § 200.303

Finding Number 2025-004 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description: The City lacked adequate controls to ensure annual reviews were conducted in accordance ...

Finding Number 2025-004 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development, Home Investment Partnerships Program Condition: Original Finding Description: The City lacked adequate controls to ensure annual reviews were conducted in accordance with its policy, limiting its ability to exercise proper oversight of eligibility determinations performed by the program’s contractor. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Julie Schneider Anticipated completion date: July 2025 Planned Corrective Action: This finding is timing related and was resolved by the City during fiscal year. The City reviewed and updated its policies and procedures to help ensure proper segregation of duties and proper oversight of eligibility determination. Additional processes now have independent review of inspections after the program’s contractor to further support program compliance. Review responsibilities were put in place to help ensure determinations receive an independent secondary review by City staff. These changes were in place by year-end. The City will continue to monitor the program and review procedures to ensure continued compliance and to prevent the recurrence of similar timing-related issues. The City will continue to monitor the program and review procedures to ensure continued compliance and to prevent the recurrence of similar timing-related issues.

View Audit 380442

Finding 1168582 (2025-003)

Material Weakness 2025

City of Detroit, Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Finding Number: 2025-003 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development (HUD), Home Investment Partnerships Program Condition: Original Finding Description: The requirements mandate that units be inspected, deficiencies communicated, and ...

Finding Number: 2025-003 Federal Program, Assistance Listing Number and Name: ALN 14.239, Department of Housing and Urban Development (HUD), Home Investment Partnerships Program Condition: Original Finding Description: The requirements mandate that units be inspected, deficiencies communicated, and corrective actions taken promptly. However, controls over housing quality standards are not effectively designed, reflecting a persistent lack of segregation of duties necessary to ensure compliance. Furthermore, existing controls were insufficient to guarantee that HQS inspection requirements were met and that identified deficiencies were addressed in a timely manner. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Julie Schneider Anticipated completion date: July 2025 Planned Corrective Action: During the fiscal year, the City reviewed and enhanced its internal controls over HQS inspections to strengthen oversight and segregation of duties. Process changes were implemented to ensure that inspections, documentation of deficiencies, follow-up actions, and certifications of completion have independent review and approval. In addition, management implemented monitoring procedures to track inspection schedules to help ensure HQS requirements are met in a timely manner.While corrective actions were initiated during the fiscal year, they were not fully implemented throughout the entire period. By year-end, the controls were in place. The City will continue to monitor these controls to ensure ongoing compliance and to prevent similar issues from recurring.

View Audit 380442

Finding 1168543 (2025-003)

Material Weakness 2025

Towner County Hospital Authority

ND

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

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management w...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliationfor the program's reserve fund is completed with formal documentation notingthe review. The CFO will reconcile the bank statement and will sign off on the bank statement, alongwith the CEO for the reserve accounts. Responsible Individuals: Tammy Larson, CFO Anticipated Completion Date: January 1, 2026

View Audit 380424

Finding 1168468 (2025-001)

Material Weakness 2025

Town of Amite City

LA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.302 § 200.303 § 200.305 § 200.318 § 200.326

The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 1 6, 2022, to administer the federal grants to ensure that the Town would comply with all federal program requirements. The Town was led to believe that...

The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 1 6, 2022, to administer the federal grants to ensure that the Town would comply with all federal program requirements. The Town was led to believe that they were in compliance with all federal program requirements. The Town will develop, formally adopt, and implement written policies and procedures to comply with Uniform Guidance (2 CFR 200).

View Audit 380288

Finding 1168368 (2025-006)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs § 200.303

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During ...

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Action Taken: The internal audit process has been redesigned and expanded to include weekly reviews and all exceptions/errors will be corrected and the cause determined. Additional training will be provided with the expectation that the exceptions/errors will reduce going forward. Effectivity Date: This will be fully implemented by 1/31/2026

View Audit 380161

Finding 1168160 (2025-002)

Material Weakness 2025

Commonspirit Health

IL

Eligibility Subrecipient Monitoring Material Weakness § 200.303

REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...

REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025

View Audit 379941

Finding 1168159 (2025-001)

Material Weakness 2025

Commonspirit Health

IL

Allowable Costs / Cost Principles § 200.303 § 200.430

REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria wi...

REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The timecards and the allocation spreadsheet are included in the reimbursement request. Beginning in January 2026, the salary allocation spreadsheet and timecards will be reviewed and signed off by the Director of Outpatient Programs as part of the reimbursement request approval process. Additionally, timecard approval compliance for prior periods will be reviewed during Bailey-Boushay weekly leadership meetings. Person Responsible: Rob Hays, Executive Director – Bailey-Boushay House Expected Completion: January 2026

View Audit 379941

Finding 1168094 (2025-001)

Material Weakness 2025

Pike County School Corporation

IN

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

FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking 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 A...

FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking 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 Treasurer of Pike County School Corporation will work with Exceptional Children’s Co-op on proportionate share expenditures. PCSC will also track those expenditures in a separate line along with revenue received for the proportionate share. Anticipated Completion Date: This method was implemented in the 2025-2026 school year and will continue with each school year as needed.

View Audit 379831

Finding 1168092 (2025-002)

Material Weakness 2025

Pike County School Corporation

IN

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

FINDING 2025-002 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Missy Schultheis Contact Phone Number and Email Address: 812-354-8478 mschultheis@pcsc.k12.in.us Views of Responsible Officials: We concur with the fin...

FINDING 2025-002 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Missy Schultheis Contact Phone Number and Email Address: 812-354-8478 mschultheis@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation will review and update the existing procurement policy to ensure it clearly outlines the procedures for different purchasing methods including the specific thresholds. We will establish a procedure requiring the retention of all documentation supporting procurement decisions. We will develop a process to verify that vendors/contractors are not suspended or debarred by any federal or state agency prior to entering into a "covered transaction" or contract. Anticipated Completion Date: This be implemented in the 2025-2026 school year and will continue for future years.

View Audit 379831

Finding 1167901 (2025-001)

Material Weakness 2025

Coldwater Community Schools

MI

Internal Control / Segregation of Duties Cash Management Reporting § 200.303

Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when ...

Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when a physical count is conducted, the figures are verified by a second staff member for accuracy. Additionally, it will be required that all supporting documentation be submitted to the Chief Financial Officer (CFO) along with the claim figures. The CFO will review and compare the documentation against the data entered into the claiming system prior to the submission of the claim.; Anticipated Completion Date: 08/01/2025

View Audit 379369

Finding 1167759 (2025-009)

Material Weakness 2025

Joint School District No. 28-J of the Counties of Adams and Arapahoe

CO

Student Financial Aid Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to v...

Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to verify the integrity, accuracy, or compliance of the systems managed by the vendor. There were no documented controls, service-level agreements, or monitoring procedures in place. Planned Corrective Action: The School District will establish formal oversight procedures for all third-party vendors supporting financial aid functions. This will include developing and maintaining service-level agreements, implementing documented monitoring and testing protocols, and conducting periodic reviews to verify system accuracy, data integrity, and federal compliance. Staff will be trained on these updated processes to ensure ongoing accountability. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026

View Audit 379034

Finding 1167665 (2025-004)

Material Weakness 2025

Town of North Haven, Connecticut

CT

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency § 200.303

Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although ret...

Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although retroactive pay for hours worked prior to ratification was correctly calculated and paid, the payroll system continued using the prior contract’s rate for all subsequent pay periods through the end of the school year. This occurred due to a failure in the payroll update process following contract implementation. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Board of Education will implement additional controls over payroll updates and establish a documented process for updating pay rates immediately after contract ratification. Additionally, review and verification of rate changes, along with periodic reconciliation against approved salary schedules or union agreements, should be performed to ensure accuracy and compliance. Name of Contact Person Christian Strickland, BOE Chief Operating Officer Projected Completion Date June 30, 2025

View Audit 378913

Finding 1167614 (2025-001)

Material Weakness 2025

Nineveh-Hensley-Jackson United School Corporation

IN

School Nutrition Programs Matching / Level of Effort / Earmarking Eligibility § 200.303

FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Jacob Heuchan, Business Manager Contact Phone Number and Email Address: 317-878-2100, jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Descripti...

FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Jacob Heuchan, Business Manager Contact Phone Number and Email Address: 317-878-2100, jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager and Food Service Director will work together to implement a system of controls surrounding eligibility. The Business Manager and Food Service Director will meet on a regular basis to verify eligibility outcomes to ensure accuracy. Anticipated Completion Date: Immediate. INDIANA STATE

View Audit 378845

Finding 1167594 (2025-002)

Material Weakness 2025

Msad #27

ME

Allowable Costs / Cost Principles Procurement, Suspension & Debarment School Nutrition Programs § 200.303

SIGNIFICANT DEFICIENCIES, 2025-002 Allowable Costs and Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval ...

SIGNIFICANT DEFICIENCIES, 2025-002 Allowable Costs and Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval for the purchase and coding to ensure it is charged to the correct accounts. Corrective Action: The District already has a requisition/purchase order system in place and will expand it to ensure purchases are pre-approved and that invoices are approved and that the purchase is coded to the appropriate fund. Anticipated Completion Date: This corrective action has already been implemented. Status: Completed.

View Audit 378769

Finding 1167495 (2025-001)

Material Weakness 2025

Dima Iii, Inc.

DE

Internal Control / Segregation of Duties § 200.303

1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA III, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation...

1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA III, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: We have instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Financial Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Director of Housing & Compliance. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

View Audit 378545

Finding 1167493 (2025-001)

Material Weakness 2025

Dima X, Inc.

DE

Internal Control / Segregation of Duties § 200.303

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA X, Inc. requires segregation of duties. We recognize that the current structure does not adequately sepa...

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA X, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: We have instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Financial Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Director of Housing & Compliance. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

View Audit 378544

Finding 1167492 (2025-001)

Material Weakness 2025

Dima Ii, Inc.

DE

Internal Control / Segregation of Duties § 200.303

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA II, Inc. requires segregation of duties. We recognize that the current structure does not adequately sep...

A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation: We concur with the finding that DIMA II, Inc. requires segregation of duties. We recognize that the current structure does not adequately separate key financial responsibilities, which could lead to potential risks. Segregation of duties is essential to maintaining the integrity of our operations and ensuring that no single individual has unchecked control over critical financial or compliance-related processes. b. Action(s) Taken or Planned on the Finding: 1. Implemented Monthly Oversight Meetings: We have instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight. 2. Hired Key Finance Staff to Support Segregation of Duties: To improve internal controls, we have hired a new Chief Financial Officer with expanded responsibilities over the accounting functions of the housing entities. We have also hired a Senior Director of Housing & Compliance. These hires have significantly enhanced our ability to segregate duties. We are currently in the process of formalizing these new roles, along with related internal controls and procedures, to establish a more robust control environment.

View Audit 378543

Finding 1167429 (2025-003)

Material Weakness 2025

Lutheran Social Services of South Dakota

SD

Special Tests & Provisions HUD Housing Programs Significant Deficiency § 200.303

Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing fr...

Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing from the participant file. No case activity or other documentation was able to be provided to indicate that these visits were conducted in accordance with the federal program. b. One instance was identified where an expense was paid and reimbursed under the grant without evidence of a formal request, invoice support, review, or approval. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on required documentation needed to maintain a complete case file, and that documentation is being completed and retained. Anticipated Completion Date: December 31, 2025

View Audit 378522

Finding 1167428 (2025-002)

Material Weakness 2025

Lutheran Social Services of South Dakota

SD

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency § 200.303

Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was...

Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was written. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on the proper sequence of approval and release of checks. Where appropriate, procedures may be modified to ensure proper approval is obtained and documented, prior to checks being delivered to clients. Anticipated Completion Date: December 31, 2025

View Audit 378522

Finding 1167427 (2025-001)

Material Weakness 2025

Lutheran Social Services of South Dakota

SD

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

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one mont...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one month. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on how to calculate eligibility, and to ensure proper documentation is retained when there are barriers to determining that eligibility. Anticipated Completion Date: December 31, 2025

View Audit 378522

Finding 1167423 (2025-003)

Material Weakness 2025

Batesville Community School Corporation

IN

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

FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in.us View...

FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will request and review weekly wage reports for all Davis-Bacon Act projects. Documents will be reviewed and signed off by the Director of Operations and kept for audit. Anticipated Completion Date: Immediately 12/08/2025

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