Corrective Action Plans

Finding 386447 (2023-002)

Material Weakness 2023

Franklin County Medical Center, A Component Unit of Franklin Countyid

ID

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Corrective action planned: Utilize a CPA experienced with federal award to review and ensure compliance with grant proposals and activities. Anticipated completion date: April 30, 2024 Contact person responsible for corrective action: Jalen Tollefson, Grant Director

View Audit 298791 Questioned Costs: $1

Finding 386441 (2023-001)

Significant Deficiency 2023

Aptakisic-Tripp Community Consolidated School District 102

IL

Reporting

The District will implement a process to track the submission time of the data collection form and audit package.

View Audit 298785

Finding 386440 (2023-004)

Significant Deficiency 2023

T.a. Lawson State Community College

AL

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Management’s Response: The College will strengthen its policies and procedures to ensure documentation of review and approvals for reporting to ensure reporting compliance. Anticipated Completion Date: February 28, 2024

View Audit 298782

Finding 386431 (2023-003)

Significant Deficiency 2023

Elkhart and St. Joseph Counties Head Start Consortium

IN

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

Finding 2023-003 – Head Start Cluster – Reporting Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all required federal reports h...

Finding 2023-003 – Head Start Cluster – Reporting Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all required federal reports have a documented, formal review of the reports before they are submitted to ensure the information submitted is accurate Anticipated Completion Date: April 2024

View Audit 298777

Finding 386428 (2023-002)

Significant Deficiency 2023

Elkhart and St. Joseph Counties Head Start Consortium

IN

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

Finding 2023-002 – Head Start Cluster – Equipment Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will add the equipment to our capital asse...

Finding 2023-002 – Head Start Cluster – Equipment Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will add the equipment to our capital asset listing and ensure inventories are performed at least every two years. Anticipated Completion Date: April 2024

View Audit 298777

Finding 386425 (2023-001)

Material Weakness 2023

Elkhart and St. Joseph Counties Head Start Consortium

IN

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

Finding 2023-001 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Act...

Finding 2023-001 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all vouchers are reviewed by a secondary individual, all supporting backup is maintained for each claim, and all payroll amounts agree to approved contracts. Anticipated Completion Date: April 2024

View Audit 298777 Questioned Costs: $1

Finding 386418 (2023-002)

Significant Deficiency 2023

Brown County Community Unit School District #1

IL

Procurement, Suspension & Debarment

Condition: The District did not solicit bids from qualified vendors for the purchase of milk products. Plan: The District will solicit bids from qualifying vendors for the purchase of milk products. Anticipated Date of Completion: June 20, 2024 Name of Contact Person: Lan Eberle, Superintendent Mana...

Condition: The District did not solicit bids from qualified vendors for the purchase of milk products. Plan: The District will solicit bids from qualifying vendors for the purchase of milk products. Anticipated Date of Completion: June 20, 2024 Name of Contact Person: Lan Eberle, Superintendent Management Response: There is no disagreement. The District will implement policies to solicit bids from qualifying bidders in future years.

View Audit 298764

Finding 386417 (2023-002)

Material Weakness 2023

Scioto Paint Valley Mental Health Center

OH

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding No. 2023-02: Cash Management During the year, a condition was noted that $87,640 of federal funds were drawn and were not expended in a timely manner. Management recognizes the important of complying with federal reporting guidelines and repaid the federal funds on September 1, 2023. In ad...

Finding No. 2023-02: Cash Management During the year, a condition was noted that $87,640 of federal funds were drawn and were not expended in a timely manner. Management recognizes the important of complying with federal reporting guidelines and repaid the federal funds on September 1, 2023. In addition, as a response to finding 2023-02, efforts will be made to ensure that federal funds are only drawn to reimburse the Organization for eligible expenses previously incurred. If funds must be drawn in advance, management will establish policies and procedures that are consistent with the Uniform Guidance administrative requirements to ensure the funds are expended in a timely manner.

View Audit 298749 Questioned Costs: $1

Finding 386415 (2023-001)

Material Weakness 2023

Scioto Paint Valley Mental Health Center

OH

Questioned Costs Allowable Costs / Cost Principles

Finding No. 2023-01: Allowable Costs (Time and Effort) In finding 2023-01, a condition was noted that salaries and wages charged to the Opioid STR (ALN 93.788) federal award were based on preliminary time and effort estimates. Employees and clinical staff track their time by the grant/program but ac...

Finding No. 2023-01: Allowable Costs (Time and Effort) In finding 2023-01, a condition was noted that salaries and wages charged to the Opioid STR (ALN 93.788) federal award were based on preliminary time and effort estimates. Employees and clinical staff track their time by the grant/program but actual time was not reconciled to the preliminary time and effort estimates before billed. As a response, the Organization updated its timekeeping system to include pay codes to allow every employee to input their actual time and effort for each specific grant. The timecards will be completed by each employee and reviewed by their supervisor. This updated timekeeping system will ensure salaries and wages charged to federal grants is based on actual time and effort. The updated timekeeping system was implemented in December 2023.

View Audit 298749 Questioned Costs: $1

Finding 386404 (2023-001)

Significant Deficiency 2023

Municipality of San German

PR

Reporting Significant Deficiency

The Municipality of San Germán always issues the audit reports on time, the exception was on June 30, 2022 because this year the disaster of Hurricane Fiona passed for Puerto Rico. This complicated all the situation for the Municipality. For this year, the report will be filed on time.

View Audit 298745

Finding 386400 (2023-002)

None 2023

Galva Community Unit School District No. 224

IL

Questioned Costs Subrecipient Monitoring Cash Management § 200.305

Condition - The District's expenditure report filed for June 30, 2023 included expenditures that were not disbursed as of June 30, 2023. These amounts were not reported as committed or obligated and were not liquidated within 90 days of the end of the fiscal year. Plan - Management will monitor exp...

Condition - The District's expenditure report filed for June 30, 2023 included expenditures that were not disbursed as of June 30, 2023. These amounts were not reported as committed or obligated and were not liquidated within 90 days of the end of the fiscal year. Plan - Management will monitor expenditure reports to ensure that amounts claimed have been disbursed prior to submitting the report or included them as obligated. Anticipated Date of Completion - June 30, 2024. Management Response - There is no disagreement with this finding and management will monitor all future federal reimbursement requests. Committed or obligated expenditures will be reported appropriately, and will be liquidated within 90 days of the end of the fiscal year.

View Audit 298743 Questioned Costs: $1

Finding 386396 (2023-001)

Material Weakness 2023

Galva Community Unit School District No. 224

IL

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.305

Condition - The District does not have internal controls in place to prevent expenditure reports being submitted that include expenditures that have not been spent, committed, or obligated. Plan - Management will implement internal controls to ensure proper expenditure reports are being submitted. ...

Condition - The District does not have internal controls in place to prevent expenditure reports being submitted that include expenditures that have not been spent, committed, or obligated. Plan - Management will implement internal controls to ensure proper expenditure reports are being submitted. Anticipated date of Completion - June 30, 2024. Name of Contact Person - Jerry Becker, Superintendent. Management Response - There is no disagreement. The District will implement internal controls to ensure expenditure reports are being submitted accurately.

View Audit 298743

Finding 386393 (2023-001)

Significant Deficiency 2023

Children's Home and Aid Society of Illinois

IL

Procurement, Suspension & Debarment

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND OTHER MATTERS 2023-001: Procurement Recommendation: We recommend that the Agency follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE AND OTHER MATTERS 2023-001: Procurement Recommendation: We recommend that the Agency follow the current policies and procedures over covered transactions to maintain documentation supporting the procurement for 5 years following the end of the contract. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to following the procurement process and requirements outlined within the policies and procedures. Name of the contact person responsible for corrective action: Angelica Stapert, Senior Vice President and CFO Planned completion date for corrective action plan: Immediately

View Audit 298740

Finding 386390 (2023-001)

Significant Deficiency 2023

Gleaners Food Bank of Indiana, INC

IN

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

U.S. Department of Agriculture 2023 - 003 Food Distribution Cluster – Assistance Listing No. 10.568, 10.569 Recommendation: We recommend that Gleaners review its process and procedures to ensure all control sign-offs are maintained on receipts. Explanation of disagreement with audit finding: There i...

U.S. Department of Agriculture 2023 - 003 Food Distribution Cluster – Assistance Listing No. 10.568, 10.569 Recommendation: We recommend that Gleaners review its process and procedures to ensure all control sign-offs are maintained on receipts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has reviewed the process and procedures with department manager and new staff. Management will follow up quarterly to verify the process is completed accordingly. Names of the contact persons responsible for corrective action: Tiffany Stead and Joseph Slater Planned completion date for corrective action plan: 10/1/2023.

View Audit 298731

Finding 386389 (2023-002)

Significant Deficiency 2023

The Housing Authority of the City of Hot Springs

AR

HUD Housing Programs Special Tests & Provisions

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit le...

Condition and Criteria: The Authority’s purpose for existence is providing decent safe and affordable housing to low-income persons. As such, HUD requires the Authority to comply with special tests and provisions relating to its Housing Choice Voucher program. The Authority must inspect the unit leased to a family at least annually to determine if the unit meets Housing Quality Standards (HQS) and the Authority must conduct quality control re-inspections. The Authority must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). Population and Items Tested: Per Table 10-1 of the Housing Choice Voucher Guidebook, the Authority was required to perform 19 quality control housing reinspections. Ten quality control re-inspections could be documented. Auditor’s Recommendation: The Authority should perform housing quality control re-inspections according to HUD guidelines. Grantee Response: We will comply with the auditor’s recommendation. Anticipated Completion Date: June 30, 2024

View Audit 298714

Finding 386388 (2023-001)

Significant Deficiency 2023

The Housing Authority of the City of Hot Springs

AR

HUD Housing Programs Eligibility

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe and affordable housing to low- income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of...

Condition and Criteria: The Authority’s purpose for existence is providing decent, safe and affordable housing to low- income persons. As such, the Authority prepares a file for each admitted family, which contains information necessary to determine eligibility for assistance and calculations of rent assistance to be paid on the family’s behalf. HUD regulations prescribe the content of these family files. These requirements consist of the following: a. As a condition of admission or continued occupancy, require the tenant and other family members to provide necessary information, documentation, and releases for the PHA to verify income eligibility. b. For both family income examinations and reexaminations, obtain and document in the family file third party verification of: (1) reported family annual income; (2) the value of assets; (3) expenses related to deductions from annual income; and (4) other factors that affect the determination of adjusted income or income-based rent. c. Determine income eligibility and calculate the tenant’s rent payment in accordance with HUD regulations. d. Select tenants from the public housing waiting list in accordance with the PHA’s tenant selection policies. e. Reexamine family income and composition at least once every 12 months and adjust the tenant rent and housing assistance payment as necessary. Population and Items Tested: Testing of sixty family files revealed the following deficiencies: 1. Two lacked documentation of rent reasonableness. 2. One file contained a HAP contract not signed by the owners. 3. Two files calculated an incorrect housing assistance payment. 4. One file lacked signed Form 9886 authorization for the period under review. Auditor’s Recommendation: A thorough review of tenant files should be performed for the purpose of eliminating the deficiencies. Grantee Response: We will comply with the auditor’s recommendation.

View Audit 298714

Finding 386386 (2023-001)

Significant Deficiency 2023

Fairleigh Dickinson University

NJ

Student Financial Aid Special Tests & Provisions Reporting

Management agrees with the recommendation. Corrective action by Associate VP of Enrollment Services and University Registrar is as follows: The Office of Enrollment Services has a supplemental procedure in place to capture students who graduate after the initial file submission to the National Stude...

Management agrees with the recommendation. Corrective action by Associate VP of Enrollment Services and University Registrar is as follows: The Office of Enrollment Services has a supplemental procedure in place to capture students who graduate after the initial file submission to the National Student Clearinghouse. To avoid any oversight in the future, the Office of Enrollment Services will enhance the edit report process and frequency. Effective immediately, the edit report will be generated every thirty days by the Compliance Officers to ensure all manual updates to a prior graduation are captured within the sixty-day requirement.

View Audit 298712

Finding 386321 (2023-001)

Material Weakness 2023

Grand Valley State University

MI

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

The University implemented a new grant management software that will provide greater functionality to complete the effort certification process within the time requirements as identified in the University's Time and Effort Reporting policy.

View Audit 298711

Finding 386320 (2023-002)

Material Weakness 2023

Grand Valley State University

MI

Subrecipient Monitoring Material Weakness Reporting

When the University is unable to access the FFATA system, University staff will capture a screen snip of the error message and save it to the secure shared drive and follow-up with an email to the system’s help desk prior to the 30-day reporting requirement.

View Audit 298711

Finding 386319 (2023-001)

Material Weakness 2023

Caritas

VA

Procurement, Suspension & Debarment

We acknowledge the deficiency highlighted in your report regarding the lack of proper internal controls over compliance with suspension and debarment regulations, particularly in relation to our Health and Human Services contract. We understand the significance of adhering to these requirements and ...

We acknowledge the deficiency highlighted in your report regarding the lack of proper internal controls over compliance with suspension and debarment regulations, particularly in relation to our Health and Human Services contract. We understand the significance of adhering to these requirements and recognize the potential risks associated with non-compliance. The cause of this deficiency, as identified, stems from the organization’s unawareness of the suspension and debarment compliance requirement in relation to staff working on the respective contract. We appreciate your thoroughness in identifying the root cause of the issue. While we are relieved that the sampling conducted during the audit did not reveal any suspended or debarred employees working under the contract during the year ended June 30, 2023, we understand the importance of establishing robust internal controls to prevent such occurrences in the future. In response to your recommendation, management has established a process and policy to ensure full compliance with suspension and debarment requirements. CARITAS will search for individuals listed on the government site on a quarterly basis and will retain notes on the search in a folder to document the review.

View Audit 298709

Finding 386309 (2023-005)

Significant Deficiency 2023

Marymount University

VA

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: We recommend the University evaluate its procedures and a policy around how level of education is determined and verified when packaging and awarding students. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...

Recommendation: We recommend the University evaluate its procedures and a policy around how level of education is determined and verified when packaging and awarding students. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Marymount University experienced high turnover in the Office of Financial Aid from the Director down to the counselor position in the 22-23 academic year. In that transition, Attain partners was contracted in late 2022 as interim staffing. For the one student in the finding that was found to have received a grade level 3 loan instead of level 2 based on the number of credits completed, research found that a rule setting in Ellucian Colleague caused the student to be auto-packaged at level 3 and it was accepted and disbursed in COD (Common Origination & Disbursement). Moving forward, Attain Partners will work with Marymount IT to update any rule settings to catch this issue and provide the Marymount Financial Aid office with internal controls that will catch any issues for the current aid year. Management notes that this issue arose due to a software programming error tied to an updated rule setting in Ellucian Colleague. Moving forward staff in Financial Aid will work in tandem with colleagues in Information Technology to review all updated rule setting in order to catch and address potential miscalculations. Name(s) of the contact person(s) responsible for corrective action: Meghan Sutton, Interim Director of Financial Aid, 703.284.1532 Planned completion date for corrective action plan: May 2024

View Audit 298705 Questioned Costs: $1

Finding 386305 (2023-004)

Significant Deficiency 2023

Marymount University

VA

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Recommendation: We recommend that the University put a process in place to refund student credit balances that arose from federal funds within 14 days. We also recommend that postings to student accounts of institutional charges for each payment period be posted and dated prior to disbursing federal...

Recommendation: We recommend that the University put a process in place to refund student credit balances that arose from federal funds within 14 days. We also recommend that postings to student accounts of institutional charges for each payment period be posted and dated prior to disbursing federal funds to limit the number of refund checks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Student refunds will be processed weekly allowing enough time to correct any errors before the end of the 14 day period. Name(s) of the contact person(s) responsible for corrective action: Mutale Sokoni, Associate Vice President for Finance, 703-284-1496 Planned completion date for corrective action plan: March 2024

View Audit 298705

Finding 386304 (2023-003)

Significant Deficiency 2023

Marymount University

VA

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...

Recommendation: We recommend the University review its reporting procedures to ensure that enrollment and program information is accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The findings were a result of data entry or date errors. Moving forward the Registrar's Office will have a second staff member review files prior to submission to ensure the accuracy of the submission to the National Student Clearinghouse. The Registrar's Office will notify Financial Aid of NSC submission dates so the FA team can verify accuracy in NSLDS. Name(s) of the contact person(s) responsible for corrective action: Dr. Meghan Arias, University Registrar, 703-284-1526 Planned completion date for corrective action plan: 3/24/24 - date of next file submission

View Audit 298705

Finding 386303 (2023-002)

Significant Deficiency 2023

Marymount University

VA

Student Financial Aid Subrecipient Monitoring Significant Deficiency

Recommendation: We recommend that the University engage a third party or perform the risk assessment for the areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement wi...

Recommendation: We recommend that the University engage a third party or perform the risk assessment for the areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Acquired Isora GRC, a software tool to facilitate and document compliance with GLBA requirements and the corresponding NIST 800-171 information security framework. Management has also created an Enterprise Risk Management Committee which will incorporate compliance with GLBA as a top priority. Name(s) of the contact person(s) responsible for corrective action: Carl Whitman, Associate Vice President and Chief Information Officer (703-526-6901) Planned completion date for corrective action plan: Action plan by June 1, 2024, including decision regarding use of a third party or in-house resources to perform the risk assessment. Completion of 90% of action plan items within one year.

View Audit 298705

Finding 386302 (2023-002)

Significant Deficiency 2023

Calaveras County Water District

CA

Subrecipient Monitoring Period of Performance Reporting § 200.344

Finding 2023-002 – Significant Deficiency Assistance List Number: 97.039 – Hazzard Mitigation Grant Pass-through Agency: California Governor’s Office of Emergency Services, FEMA-4344-DR-CA. Compliance Requirement: Reporting. Condition: The District did not provide project closeout materials to th...

Finding 2023-002 – Significant Deficiency Assistance List Number: 97.039 – Hazzard Mitigation Grant Pass-through Agency: California Governor’s Office of Emergency Services, FEMA-4344-DR-CA. Compliance Requirement: Reporting. Condition: The District did not provide project closeout materials to the pass-through agency within 90 days of the end of the period of performance so the pass-through agency could prepare the closeout reporting within 120 days of the end of the period of performance. Criteria: The Notice of Funding Opportunity indicates: “In addition, pass-through entities are responsible for closing out their subawards as described in 2 C.F.R. § 200.344; subrecipients are still required to submit closeout materials within 90 calendar days of the period of performance end date. When a subrecipient completes all closeout requirements, pass-through entities must promptly complete all closeout actions for subawards in time for the recipient to submit all necessary documentation and information to FEMA during the closeout of the prime award.” Cause: The District’s staff were waiting for a requested extension for the period of performance from the pass-through agency and assumed the closeout reporting would not be necessary. Effect: The District is not in compliance with the terms and conditions of the federal award. Recommendation: We understand the District provided the information necessary to complete the closeout reporting to the pass-through agency on November 30, 2023. Views of Responsible Officials and Planned Corrective Actions: As indicated in the recommendation, the District provided the information necessary to complete the closeout reporting to the pass-through agency on November 30, 2023. Furthermore, on March 22, 2024, the District heard from the pass-through agency that FEMA received the requested extension, and it is in the queue for final approval and signature. The corrective action has been completed.

View Audit 298704

Corrective Action Plans

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