Corrective Action Plans

Finding 382343 (2023-004)

Material Weakness 2023

IN

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

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistanc...

FINDING 2023-004 Information on the federal program: Subject: Child Nutrition Cluster - Reporting Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness Contact Person Responsible for Corrective Action: Chris Akers, Treasurer Contact Phone Number and Email Address: (219) 838-1819 cakers@lakeridgeschools.net Condition: The School Corporation had not properly designed or implemented a system of internal control, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting noncompliance related to the monthly sponsor claim for reimbursement. Context: School Food Authority’s (SFA) and sponsors must submit monthly claims for reimbursement for meals and snacks served to eligible students within 60 days following the last day of the month covered by the claim. The Food Service Management Company employed Food Service Director prepared the monthly claim for reimbursement on the Indiana Department of Education Child Nutrition Program website based on meal count reports from the point-of-sale system. The School Corporation did not implement a system of internal control to ensure what was claimed for reimbursement agreed to the point-of-sale system meal count reports. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Before the monthly claim for reimbursement is submitted by the FSMC, the Treasurer will reconcile the claim with the meal count report generated by the point-of-sale system. Anticipated Completion Date: Immediate

View Audit 296034

Finding 382335 (2023-003)

Material Weakness 2023

Lake Ridge Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403 § 200.421 § 200.445 § 200.467

FINDING 2023-003 Information on the federal program: Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program fo...

FINDING 2023-003 Information on the federal program: Subject: Child Nutrition Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Federal Agency: Department of Agriculture Federal Programs: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children, Fresh Fruit and Vegetable Program Assistance Listings Numbers: 10.553, 10.555, 10.559, 10.582 Federal Award Number and Year (or Other Identifying Numbers): FY2021-2022, FY2022-2023 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Reporting Audit Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Adrian Wilkerson, Chief Financial Officer Contact Phone Number and Email Address: (219) 838-1819 awilkerson@lakeridgeschools.net Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed and the Allowable Costs/Cost Principles. Context: The School Corporation had not designed or implemented a system of internal control to ensure that program costs incurred by the Food Service Management Company were supported by proper documentation and were allowable. The School Corporation entered into a cost reimbursement contract with a food service management company (FSMC). The FSMC incurred costs and invoiced the School Corporation for reimbursement of the costs. Due to the lack of effective internal controls, the following errors were noted: In a test of 44 items, 22 items (50%) totaling $6,641 did not have proper documentation to support that the expenses were allowable and for the benefit of food service. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In addition to the monthly review of the FSMC invoice and budget, the Chief Financial Officer will review and approve the supporting documentation (invoices, payroll records) provided by the FSMC to ensure that expenses are allowable and for the benefit of food service. Anticipated Completion Date: Immediate

View Audit 296034 Questioned Costs: $1

Finding 382332 (2023-002)

None 2023

Cicero Commons Senior Housing Development Fund Company, Inc.

NY

HUD Housing Programs Cash Management

U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independ...

U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: July 1, 2022 – June 30, 2023 The findings from the 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None Finding 2023-002: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Condition: The required deposit of $1,556 for the year ended June 30, 2022 was made after the 60 day deadline. Recommendation: Lucille Apartments should ensure residual receipts are made within 60 days of year-end in accordance with the HUD Regulatory Agreement. Action Taken: The required deposit was made in September 2022. Completion Date: September 2022 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO (315) 424-1821

View Audit 296031

Finding 382331 (2023-001)

None 2023

Cicero Commons Senior Housing Development Fund Company, Inc.

NY

HUD Housing Programs

U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independ...

U.S. Department of Housing and Urban Development Cicero Commons Senior Housing Development Fund Company, Inc. (Lucille Manor Apartments), HUD Project No. 014-EE070-NY06-S941-009 respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: July 1, 2022 – June 30, 2023 The findings from the 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2023-001: Supportive Housing for the Elderly (Section 202), Federal Assistance Listing Number 14.157 Recommendation: Our auditors recommended that we make the remaining $955 deposit into the reserve for replacements when cash flow was sufficient. Action Taken: Lucille Manor Apartments made the required payment was made in July 2023. Completion Date: July 2023 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO (315) 424-1821

View Audit 296031

Finding 382330 (2023-001)

None 2023

St. Luke Hsg Dev Fund Company (st. Luke Apts) 014-11157

NY

HUD Housing Programs Procurement, Suspension & Debarment

U.S. Department of Housing and Urban Development St. Luke Apartments St. Luke Housing Development Fund Company, Inc. (St. Luke Apartments), FHA Project No. 014-11157 respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent pub...

U.S. Department of Housing and Urban Development St. Luke Apartments St. Luke Housing Development Fund Company, Inc. (St. Luke Apartments), FHA Project No. 014-11157 respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 North Franklin Street #60 Syracuse, New York 13204 Audit period: October 1, 2022 – September 30, 2023 The findings from the 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT None FINDINGS – FEDERAL AWARD PROGRAM AUDIT Finding 2023-001: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 Recommendation: St. Luke Apartments should ensure residual receipts are made within 60 days of year-end in accordance with the HUD Regulatory Agreement. Action Taken: St. Luke Apartments made the required payment was made after the 60-day timeline. Completion Date: February 2024 Name of Contact Person Responsible for Corrective Action: Kyle Lyskawa, CFO (315) 424-1821

View Audit 296029

Finding 382329 (2023-002)

None 2023

Lbb Corp.

RI

HUD Housing Programs

Finding 2023-002: tenant assets not verified as part of recertification. Corrective action plan: management will make every effort that recertifications are complete and accurate in the future.

View Audit 296026

Finding 382328 (2023-001)

None 2023

Lbb Corp.

RI

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-001: late deposit of residual receipts. Corrective action plan: none required.

View Audit 296026

Finding 382322 (2023-004)

Material Weakness 2023

Board of Education Baltimore County

MD

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2023-004 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – ...

Finding Number: 2023-004 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – 9/30/24) 211116-01 (7/1/20 – 9/30/22) 211303-01 (7/1/20 – 9/30/22) 221499-01 (7/1/21 – 9/30/23) 221769-01 (7/1/21 – 9/30/22) Compliance Requirement: Special Test Type of Finding: Material Weakness in Internal Control over Compliance, Other Matters Recommendation: We recommend that the Board enhance its procedures and internal controls to ensure that it retains documentation to support student withdrawals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BCPS conducts regular training with the school-based staff that maintain this related student documentation. The training will include updates on collecting and maintaining written documentation to meet the requirements for removing a student form the cohort. Name(s) of the contact person(s) responsible for corrective action: Dr. Kim Ferguson, Executive Director of Student Support Services Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 296020

Finding 382316 (2023-003)

Significant Deficiency 2023

Board of Education Baltimore County

MD

Eligibility Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303

Finding Number: 2023-003 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – ...

Finding Number: 2023-003 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: Title I, Part A Assistance Listing: 84.010 Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201310-01 (7/1/19 – 9/30/21) 231095-01 (7/1/22 – 9/30/24) 211116-01 (7/1/20 – 9/30/22) 211303-01 (7/1/20 – 9/30/22) 221499-01 (7/1/21 – 9/30/23) 221769-01 (7/1/21 – 9/30/22) Compliance Requirement: Special Test Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend that the Board revises the Student Participation process to include a step that includes matching the student grade level to the corresponding school type and a step to include a second review of the Title I School eligibility address and school type by a second staff member. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: BCPS revised their procedures on Title I Equitable Services: Student Participation in early Fall 2023. Revisions outlined below will lessen the risk of potential audit findings in the future: - Revise the Student Participation process to include a step that includes matching the student grade level to the corresponding public school type. - Revise the Student Participation Process to include a second review of the Title I School eligibility address and school type by a second staff member. Name(s) of the contact person(s) responsible for corrective action: Michele Stansbury, Director of Title I Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 296020

Finding 382308 (2023-002)

Significant Deficiency 2023

Board of Education Baltimore County

MD

Allowable Costs / Cost Principles § 200.303

Finding Number: 2023-002 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing: 84.425 C,D,U,W Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201873-01 (3/13/2...

Finding Number: 2023-002 Prior Year Finding: No Federal Agency: U.S. Department of Education Federal Program: COVID-19 – Education Stabilization Fund Assistance Listing: 84.425 C,D,U,W Pass-Through Entity: Maryland State Department of Education Pass-Through Award Number and Period: 201873-01 (3/13/20 – 9/30/22) 221869-01 (6/1/22 – 9/30/24) 201787-01 (3/13/20 – 9/30/22) 211956-01 (3/24/21 – 9/30/23) 202233-01 (3/13/20 – 9/30/22) 221568-01 (7/1/21 – 9/30/22) 221422-01 (7/1/21 – 9/30/23) 221894-01 (7/1/21 – 9/30/23) Compliance Requirement: Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation We recommend that the Board enhance its procedures and internal controls to ensure that it retains documentation of expenditure approvals and that this documentation is available for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the event an employee is on unexpected extended leave, internal control processes were updated to ensure support staff members collect backup documentation of Pcard purchases and the fiscal supervisor or grant manager will work with fiscal services to reconcile procurement cards and print out summary sheets for review and signature. Name(s) of the contact person(s) responsible for corrective action: Michele Stansbury, Director of Title I Planned completion date for corrective action plan: For immediate implementation and ongoing.

View Audit 296020

Finding 382297 (2023-001)

Material Weakness 2023

Aids Ministries - Aids Assist of North Indiana, Inc.

IN

Reporting Internal Control / Segregation of Duties

2023-001 Material Adjustments Views of Responsible Officials and Planned Corrective Actions: Prior to the merger of Refresh and AIDS Ministries/AIDS Assist, the financial statements and policies for Refresh were not monitored consistently by previous management/board of directors. Since the merger R...

2023-001 Material Adjustments Views of Responsible Officials and Planned Corrective Actions: Prior to the merger of Refresh and AIDS Ministries/AIDS Assist, the financial statements and policies for Refresh were not monitored consistently by previous management/board of directors. Since the merger Refresh has adopted all financial policies of AIDS Ministries/AIDS Assist. Management will incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements and increase the accuracy of the interim financial reports used by management for Refresh accounts.

View Audit 296006

Finding 382292 (2023-002)

Significant Deficiency 2023

Contoocook Valley Regional School District

NH

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

Audit Finding Reference: 2023-002 Planned Corrective Action: Review of purchasing policy and federal procurement procedures with grant managers as well as the AP/Grant reporting staff. No purchase will be processed without proper documentation. Name of Contact Person and Completion Date: Brian Cisne...

Audit Finding Reference: 2023-002 Planned Corrective Action: Review of purchasing policy and federal procurement procedures with grant managers as well as the AP/Grant reporting staff. No purchase will be processed without proper documentation. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Anticipated Completion Date – 4/1/24

View Audit 295998 Questioned Costs: $1

Finding 382291 (2023-001)

Significant Deficiency 2023

Contoocook Valley Regional School District

NH

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Audit Finding Reference: 2023-001 Planned Corrective Action: Onboarding procedure is being changed where employees are not able to start working until a signed contract is on file in their HR file. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Michael Hatfield (...

Audit Finding Reference: 2023-001 Planned Corrective Action: Onboarding procedure is being changed where employees are not able to start working until a signed contract is on file in their HR file. Name of Contact Person and Completion Date: Brian Cisneros (Business Administrator) Michael Hatfield (HR Director) Anticipated Completion Date – 4/1/24

View Audit 295998 Questioned Costs: $1

Finding 382285 (2023-003)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Procurement, Suspension & Debarment

Finding 2023-003 – Suspension and Debarment Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Fa...

Finding 2023-003 – Suspension and Debarment Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: State of Illinois Department of Public Health Ascension Ministry Market: Illinois Pass-Through Award Numbers: 38080717K, 38080718K Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living will provide education to their associates performing initial suspension and debarment screening as part of onboarding control activities to retain evidence of their review and the supporting documentation. Management will re-assess controls over the data transfer application used to send the vendor data file to the third-party vendor, ProviderTrust. The System will explore implementing compensating controls for MatrixCare. The application is anticipated to be sunset in early 2025, when the process is migrated to Oracle Cloud and the established ProviderTrust processes. Responsible Official: Emily Hablultzel, Compliance Specialist; Leia C. Olsen, Compliance Officer-Acute Care/Regulatory/Investigations & Incidents; Noelle Fulton, Compliance Senior Director Anticipated completion date: March 30, 2024; July 01, 2024; July 01,2024

View Audit 295994

Finding 382283 (2023-004)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Cash Management

Finding 2023-004 – Reporting Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services A...

Finding 2023-004 – Reporting Information of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: State of Illinois Department of Public Health Ascension Ministry Market: Illinois Pass-Through Award Numbers: 38080717K, 38080718K Pass-Through Award Period: 07/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that nine reports were not submitted to the State as required by the grant terms. Ascension Living management will coordinate with the State representatives regarding any past reports that are needed and submit them timely according to the agreement requirements. The System implemented a team calendar that tracks due dates of all reports required to be submitted under federal and state programs. This calendar is accessible to all team members, including management. However, Ascension will reinforce the importance to management of oversight and accountability of oversight and accountability to submit required reports. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024

View Audit 295994

Finding 382282 (2023-002)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Allowable Costs / Cost Principles Cash Management Period of Performance

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Thr...

Finding 2023-002 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance Information of the federal program: Federal Grantor: United States Department of Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Pass-Through Grantor: State of Illinois Department of Healthcare and Family Services Ascension Ministry Market: Illinois Pass-Through Award Number: ARPA000420 Pass-Through Award Period: 05/01/2022-06/30/2023 Pass-Through Grantor: Mayor and City Council of Baltimore, Through MONSE Ascension Ministry Market: Maryland Pass-Through Award Number: Not applicable Pass-Through Award Period: 07/01/2022-06/30/2023 Views of responsible officials: Ascension Living management acknowledges that internal controls were not working effectively regarding review of the calculated limitations and allocations. Ascension has reserved the questioned costs and has communicated with the State on their desired method of repayment. For future grants, Ascension Living will implement controls for appropriate review and approval and to have a secondary review to validate calculations. St. Agnes Healthcare, Inc., Maryland - This finding pertains to retroactive grants where expenses were incurred in previous periods but were subsequently eligible for grant reimbursement. Management is working on creating a report to identify timecards lacking manager approval for exclusion as allowable grant expenses. Grant Accounting is incorporating Time and Effort tracking features a separate approval control to mitigate the issue of timecards lacking manager approval. Responsible Official: July Turley, Director of Accounting and Reporting; Rob Madsen, Director of Accounting and Reporting Anticipated completion date: May 31, 2024, and July 01, 2024

View Audit 295994

Finding 382278 (2023-001)

Material Weakness 2023

Ascension Health Alliance D/b/a Ascension

MO

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: United States Department of Housing and Urban Development Assistance Listing No.: 14.241, Housing Opportunities for Persons with AIDS Ascension Ministry Market: Illinois Pass-Through Grantor: Aids Foundation of Chicago...

Finding 2023-001 – Reporting Information of the federal program: Federal Grantor: United States Department of Housing and Urban Development Assistance Listing No.: 14.241, Housing Opportunities for Persons with AIDS Ascension Ministry Market: Illinois Pass-Through Grantor: Aids Foundation of Chicago Federal Grantor: United States Department of Justice Assistance Listing No.: 16.560, National Institute of Justice Research, Evaluation, and Development Project Grants Ascension Ministry Market: Texas Federal Grantor: United States Department of Justice Assistance Listing No.: 16.710, Public Safety Partnership and Community Policing Grants Ascension Ministry Market: Illinois Pass-Through Grantor: The Village of Arlington Heights Police Department Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Ascension Ministry Market: Maryland Pass-Through Grantor: Mayor and City Council of Baltimore, through MONSE Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.650, Accountable Health Communities Ascension Ministry Market: Illinois Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.958, Block Grants for Community Mental Health Services Ascension Ministry Market: Illinois Pass-Through Grantor: The State of Illinois Department of Human Services Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.039, Hazard Mitigation Grant Ascension Ministry Market: Florida Pass-Through Grantor: Florida Division of Emergency Management Views of responsible officials: The System will enhance its grant management award processes by revising its onboarding procedures and add additional controls to monitor the accuracy of the core data. Management will reinforce the importance of timeliness and accuracy of the Schedule reporting totals to facilitate accurate reporting. Award amounts were changed on the Schedule after management’s review was executed. Management will implement preventive controls to lock down market Schedule templates after management final review. Responsible Official: Rob Madsen, Director of Accounting and Reporting, Grants & Research COE Anticipated completion date: May 31, 2024

View Audit 295994

Finding 382277 (2023-002)

Significant Deficiency 2023

Bowling Green Independent School District

KY

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

In regard to the 2023-002 COVID-19 Education Stabilization Fund, a payroll record failed to be updated to the new rate per the FY2023 salary schedule and, as a result, extraduty performed by this employee was underpaid by $91 throughout the entirety of FY2023. Management had already identified the i...

In regard to the 2023-002 COVID-19 Education Stabilization Fund, a payroll record failed to be updated to the new rate per the FY2023 salary schedule and, as a result, extraduty performed by this employee was underpaid by $91 throughout the entirety of FY2023. Management had already identified the internal control error in August of 2023, identified the root cause of the error, and had implemented both preventative and detective controls as of August 2023. The controls will be adhered to with the strictest of oversight. If the Kentucky Department of Education has questions regarding this plan, please call Shaunna Cornwell

View Audit 295993

Finding 382275 (2023-003)

None 2023

Landmark College, INC

VT

Student Financial Aid

FINDING 2023-003: Pell Calculation Planned Corrective Action: The Director of Financial Aid has created a Summer Pell specific reconciliation report to ensure accurate Pell calculations. Additionally, a custom data field in our financial Aid operating system, PowerF AIDS, has been created to flag al...

FINDING 2023-003: Pell Calculation Planned Corrective Action: The Director of Financial Aid has created a Summer Pell specific reconciliation report to ensure accurate Pell calculations. Additionally, a custom data field in our financial Aid operating system, PowerF AIDS, has been created to flag all summer Pell eligible students for manual review by both the Director and the Associate Director of Financial Aid.

View Audit 295992

Finding 382274 (2023-002)

None 2023

Landmark College, INC

VT

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

FINDING 2023-002: Timely Reporting to NSLDS The Registrar and the Landmark College Database / Application Systems Analyst met with the National Student Clearinghouse (NSC) to address this issue. This discussion surfaced the information about how NSC schedules their files and the revelation that Covi...

FINDING 2023-002: Timely Reporting to NSLDS The Registrar and the Landmark College Database / Application Systems Analyst met with the National Student Clearinghouse (NSC) to address this issue. This discussion surfaced the information about how NSC schedules their files and the revelation that Covid pushed the NSC submission schedule back. As a result of the meeting, the NSC first of term file will revert to preCovid. Planned Corrective Action: The correction to reports by NSC should correct this error going forward

View Audit 295992

Finding 382273 (2023-004)

Material Weakness 2023

Rensselaer Central School Corporation

IN

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

Finding 2023-004 Information on the federal program: Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Pass-Through Entit...

Finding 2023-004 Information on the federal program: Subject: Education Stabilization Fund – Special Tests and Provisions - Wage Rate Requirements Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Audit Findings: Material Weakness, Qualified Opinion Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Special Tests and Provisions – Wage Rate Requirements compliance requirements. The School Corporation did not include Davis Bacon wage rate requirements in its contract with vendor which includes labor. The School Corporation did not obtain the weekly payroll reports certifications from a construction company and its subcontractors for a building project. Context: The School Corporation did not have an internal control designed to collect the weekly payroll reports certifications from a construction company and its subcontractors, as applicable, for building projects which included HVAC upgrades and replacements. Therefore, no review was performed by management to ensure that pay rates complied with the federal wage rate requirements. The vendor contract did not include a Davis-Bacon clause prescribing federal wage rate requirements required for construction contracts with labor installation costs. As of June 30, 2023, $566,328 was disbursed related to this capital project and charged to the ESSER III grant award (84.425U). The construction payments represented approximately 27.2% of the Education Stabilization Fund expenditures for the audit period. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. For any contracts related to projects with a cost of greater than $2,000 for the construction, alternation, or repair of public buildings or public works and which are federally funded, management will include a Davis Bacon wage rate requirement clause in the contract or request the vendor to sign a certificate or contract amendment affirming the contractor will comply with federal wage requirements. Management will designate a project manager to oversee the federally funded project and ensure the collection of the required weekly payroll wage report and document their review verifying prevailing wages are being paid to contractors. Responsible Party and Timeline for Completion: The Treasurer, Dawn Claussen, will oversee the corrective action plan which will be implemented by June 30, 2024.

View Audit 295986

Finding 382269 (2023-005)

Material Weakness 2023

Rensselaer Central School Corporation

IN

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

Finding 2023-005 Information on the federal program: Subject: Education Stabilization Fund – Equipment and Real Property Management Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Ent...

Finding 2023-005 Information on the federal program: Subject: Education Stabilization Fund – Equipment and Real Property Management Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425C, 84.425D, 84.425U Pass-Through Entity: Indiana Department of Education Compliance Requirement: Equipment and Real Property Management Audit Findings: Material Weakness  Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management Requirements compliance requirements. Context: During the testing of equipment acquisitions, it was noted the School Corporation is maintaining and updating property records, however, had not performed a physical inventory of capital assets during the period under audit. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. The Rensselaer Central Schools Corporation will hire a firm to perform a physical inventory. Responsible Party and Timeline for Completion: The Treasurer, Dawn Claussen, will oversee the correction plan which will be implemented by June 30, 2024

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Finding 382265 (2023-003)

Material Weakness 2023

Rensselaer Central School Corporation

IN

Matching / Level of Effort / Earmarking § 200.207 § 200.303

Finding 2023-003 Information on the federal program: Subject: Special Education Cluster (IDEA) –Earmarking Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Federal Award...

Finding 2023-003 Information on the federal program: Subject: Special Education Cluster (IDEA) –Earmarking Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Federal Award Numbers and Years (or Other Identifying Numbers): 20611-047-PN01, 21611-047-PN01, 20619-047-PN01, 21619-047-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Matching, Level of Effort, and Earmarking Audit Finding: Material Weakness, Other Matters Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the earmarking portion of the Matching, Level of Effort, Earmarking compliance requirement. Context: The School Corporation did not meet the earmarking requirements for the grants, which concluded during the audit period. Both the Special Education Grants to States and Special Education Preschool Grants required a proportionate share of their funding to be spent on non-public school students with disabilities. The 20611-047-PN01, 20619-047-PN01, 21611-047-PN01, 21619-047-PN01 grant awards were fully expended during the audit period with minimum Non-Public Proportionate Share earmarking requirements of $19,551, $2,421, $26,253, and $1,959, respectively. There was no supporting documentation provided to support any non-public school expenditures were incurred towards the meeting the non-public proportionate share requirement. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. The Cooperative Schools Service has developed a written procedure of documenting expenditures related to the proportionated share earmarking requirement and validate the earmarking requirement to met at the end of the grant’s period of performance or once fully expended. Responsible Party and Timeline for Completion: The correction action plan has been put into place for the 2023-24 school year. Treasurer, Dawn Claussen and Director of Cooperative School Services, Sarah Claton, will oversee the corrective action plan.

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Finding 382259 (2023-002)

Material Weakness 2023

Rensselaer Central School Corporation

IN

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

Finding 2023-002 Information on the federal program: Subject: Special Education Cluster – Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Fede...

Finding 2023-002 Information on the federal program: Subject: Special Education Cluster – Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.173 Federal Award Numbers and Years (or Other Identifying Numbers): 20611-047-PN01, 21611-047-PN01, 22611-047-PN01, 20619-047-PN01, 21619-047-PN01, 22619-047-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the program grant agreements and the compliance requirements related to suspension and debarment. Context: The School Corporation is a member of the Cooperative School Services (Cooperative) and serves as the fiscal agent for the Cooperative. The Cooperative operated the special education programs on behalf of the School Corporation and managed the special education grant funds. As the grant agreement was between the Indiana Department of Education and the School Corporation, the School Corporation was responsible for compliance with the grant agreement and the Suspension and Debarment compliance requirements. During fiscal year 2022, The School Corporation did not have adequate internal controls in place to ensure the Cooperative complied with the suspension and debarment requirements. The Special Education Director obtained suspension and debarment certifications for contracted vendors over $25,000 without an oversight or review process. The lack of controls over suspension and debarment requirements was isolated to fiscal year 2022. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Two Cooperative School Service employees will check and initial the procurement and Suspension and Debarments documentation. Management of the School Corporation will request supporting documentation from Cooperative School Services to validate procurement and suspension and debarment procedure where performed to satisfy federal regulations. Responsible Party and Timeline for Completion: The corrective action plan has been put into place by both parties. Sarah Claton, Director of Cooperative Schools Services and the Treasurer, Dawn Claussen, will oversee the corrective action plan.

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Finding 382253 (2023-004)

Material Weakness 2023

Plymouth Community School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328

FINDING 2023 - 004 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or de...

FINDING 2023 - 004 Finding Subject: COVID-19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation had not designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance. The School Corporation was to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. During the audit period the School Corporation was required to submit two ESSER I reports, two ESSER II reports, and two ESSER III reports—a total of six reports. However, the School Corporation failed to submit all six required reports. We recommended that management of the School Corporation establish a proper system of internal controls and develop policies and procedures to ensure reports are submitted. Contact Person Responsible for Corrective Action: Steven Boyer Contact Phone Number and Email Address: 574-936-3115 sboyer@plymouth.k12.in.us Views of Responsible Officials: The Corporation concurs with the finding. Description of Corrective Action Plan: The transition in the Corporation’s Business Manager position resulted in a failure to properly identify and train the person responsible for submitting final expenditure reports for ESSER grants. The Business Manager will prepare the final expenditure reports, and the Grant Specialist will review and compare the report to the ledger to verify that it is correct. After the review, the Business Manager will submit the final expenditures reports. Additionally, the Business Manager and Grant Specialist have developed a shared calendar that includes all report due dates. Anticipated Completion Date: This corrective action plan was implemented beginning February 2024 and will be implemented moving forward.

View Audit 295985

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