Corrective Action Plans

Finding 370119 (2023-002)

Significant Deficiency 2023

Jefferson County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

The County plans to check the SAM (System for Award Management formerly Excluded Parties Listing System (EPLS), which is maintained by the General Services Administration before any funds are disbursed to vendors/entities.

View Audit 291630

Finding 370118 (2023-001)

Significant Deficiency 2023

Coquille Valley Hospital District

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties

Provider Relief Fund Program – CFDA 93.498 Recommendation: CLA recommends the Health System perform review procedures over reporting expenses in a timely manner, so expenses are accurately reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Provider Relief Fund Program – CFDA 93.498 Recommendation: CLA recommends the Health System perform review procedures over reporting expenses in a timely manner, so expenses are accurately reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Health System have input of information reviewed before it is submitted. After being filled out the preparer will have another review the inputs before submitting. Name(s) of the contact person(s) responsible for corrective action: Michelle Reyna and Jennifer Stine Planned completion date for corrective action plan: March 31, 2024 If there are any questions regarding this plan, please call Michelle Reyna at (541) 396- 1067.

View Audit 291628

Finding 370108 (2023-001)

None 2023

Bridgeton Board of Education

NJ

School Nutrition Programs

ACFR/AMR Finding # 2023-001, Finding (Condition) - The School District's Food Service Fund Net Cash Resources exceeded its three-months average expenditures., Recommendation - That the School District develop a plan to reduce the Food Service Fund's Net Cash Resources below its three-month average e...

ACFR/AMR Finding # 2023-001, Finding (Condition) - The School District's Food Service Fund Net Cash Resources exceeded its three-months average expenditures., Recommendation - That the School District develop a plan to reduce the Food Service Fund's Net Cash Resources below its three-month average expenditures. Method of Implementation - The district is purchasing updated equipment throughout the various kitchens including cameras to monitor the health and safety practices of the line. We plan to review available menu options and expand quality and offerings. Person Responsible for Implementation - Director of Food Services & School Business Administrator. Implementation Date - 6/30/2024.

View Audit 291622

Finding 370101 (2023-002)

Material Weakness 2023

Westmoreland County Community College

PA

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

Finding 2023-002: Education Stabilization Fund Allowable Costs and Allowable Activities Westmoreland County Community College continued to provide the same Covid outreach programs as they had years one and two in year three to their Students and Employees and community. • Vaccination clinics were ...

Finding 2023-002: Education Stabilization Fund Allowable Costs and Allowable Activities Westmoreland County Community College continued to provide the same Covid outreach programs as they had years one and two in year three to their Students and Employees and community. • Vaccination clinics were continued and are still offered. However, these are at no cost to the University, student, or employee. • Hand sanitizer, masks and other items are always available to those who require, but were paid for from prior years funds. • When advertising for all Covid related events Westmoreland used sources which were at no cost to the college. • The staff time to organize and manage events did not get allocated to the grant, however would have been covered under the lost revenue recognition.

View Audit 291618 Questioned Costs: $1

Finding 370100 (2023-001)

Material Weakness 2023

Westmoreland County Community College

PA

Reporting

Finding 2023-001: Education Stabilization Fund Reporting WCCC does not have any funds excluded. All the reports were filed throughout the grant in a timely manner but not always correctly. A former employee filed these reports. Current staff have been working to get all the reports corrected and po...

Finding 2023-001: Education Stabilization Fund Reporting WCCC does not have any funds excluded. All the reports were filed throughout the grant in a timely manner but not always correctly. A former employee filed these reports. Current staff have been working to get all the reports corrected and posted back to the college's web site. The College grant writing/compliance employee who unfortunately left after 1 month. WCCC continues to advertise for this position along with the Asst Controller position for Grants and Foundation. The President and Director of Accounting are ensuring hiring is done. These hirings will be completed this fiscal year.

View Audit 291618

Finding 370090 (2023-005)

Material Weakness 2023

Westmoreland County Community College

PA

Questioned Costs Internal Control / Segregation of Duties

Finding 2023-005: Student Financial Assistance Cluster Gramm-Leach-Bliley Act - Student Information Security WCCC created a written information security program that addresses the required minimum elements. The condition was corrected by implementing the security plan and following the guidelines o...

Finding 2023-005: Student Financial Assistance Cluster Gramm-Leach-Bliley Act - Student Information Security WCCC created a written information security program that addresses the required minimum elements. The condition was corrected by implementing the security plan and following the guidelines of the GLBA. The plan was implemented as of 12/1/23. Moving forward we will continue to monitor the requirements of GLBA.

View Audit 291618 Questioned Costs: $1

Finding 370089 (2023-004)

Material Weakness 2023

Westmoreland County Community College

PA

Questioned Costs Special Tests & Provisions Student Financial Aid

Finding 2023-004: Student Financial Assistance Cluster Return of Title IV Funds As previously noted, the root cause was human error based on the manual processes. Similar to the previous finding, the College has implemented increased internal control through the review of the R2T4 calculations. Add...

Finding 2023-004: Student Financial Assistance Cluster Return of Title IV Funds As previously noted, the root cause was human error based on the manual processes. Similar to the previous finding, the College has implemented increased internal control through the review of the R2T4 calculations. Additionally, when using the automated functionality within the system for the return of funds calculation, an independent review of the calculation will be performed moving forward. In the future, the new ERP will increase the levels of control configured in the system. The President will ensure the controls are in place.

View Audit 291618 Questioned Costs: $1

Finding 370088 (2023-003)

Material Weakness 2023

Westmoreland County Community College

PA

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties

Finding 2023-003: Student Financial Assistance Cluster Allowable Costs and Allowable Activities and Eligibility and SEOG Pell The findings noted three separate issues related to policies and procedures verifying the accuracy of the student eligibility for grant funding and the proper amount paid to...

Finding 2023-003: Student Financial Assistance Cluster Allowable Costs and Allowable Activities and Eligibility and SEOG Pell The findings noted three separate issues related to policies and procedures verifying the accuracy of the student eligibility for grant funding and the proper amount paid to the student based on financial need. After a review of Pell grants, Return To Title IV funds, and the award of SEOG after a return of Title IV calculation, it was determined that human error as a result of manual work was the root cause. To correct the root cause, an increased level of internal control via another level of review and a re-review of aid for the FY24 year was implemented. Further, for students who had an enrollment status of less than full time, we have had increased the number reviews for compliance. Moving forward, the College is implementing a new ERP system in which internal controls are configured to alleviate manual work thus human error and increase compliance. The President will ensure the controls are in place.

View Audit 291618 Questioned Costs: $1

Finding 370086 (2023-006)

Material Weakness 2023

Evansdale Municipal Housing Authority

IA

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

Finding 2003-006: We agree with the finding. The Authority will adopt an operating budget for the Voucher program as a control to ensure operating costs are reasonable and the program remains financially viable. The Authority will put into place a system to reimburse shared expenses in a timely man...

Finding 2003-006: We agree with the finding. The Authority will adopt an operating budget for the Voucher program as a control to ensure operating costs are reasonable and the program remains financially viable. The Authority will put into place a system to reimburse shared expenses in a timely manner and will monitor the balances. The Authority will no longer grant temporary loans to other Authority programs, to be completed within thirty days.

View Audit 291615

Finding 370085 (2023-005)

Material Weakness 2023

Evansdale Municipal Housing Authority

IA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

Finding 2003-005: We agree with the finding. The Authority will enter into a General Depository Agreement HUD-51999 (GDA) with our financial institution within the next thirty days.

View Audit 291615

Finding 370084 (2023-004)

Material Weakness 2023

Evansdale Municipal Housing Authority

IA

Special Tests & Provisions Eligibility HUD Housing Programs

Finding 2003-004: We agree with the finding. However, the Authority can not reasonably adopt internal control procedures to correct the material weakness.

View Audit 291615

Finding 370076 (2023-001)

None 2023

The Methodist University, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Contact Person: Bonnie Adamson, Director of Financial Aid Corrective Action: The student that was not reported within 15 calendar days as required had several outliers making it difficult to determine Pell amounts. The student had atended another university Summer 2022 and this par􀆟cular university...

Contact Person: Bonnie Adamson, Director of Financial Aid Corrective Action: The student that was not reported within 15 calendar days as required had several outliers making it difficult to determine Pell amounts. The student had atended another university Summer 2022 and this par􀆟cular university awarded the student’s Pell Grant off of the 22-23 award year. While this is an accepted prac􀆟ce, it can affect the student’s 22-23 Pell Grant eligibility if they transfer to another ins􀆟tu􀆟on. This student did transfer to Methodist University (MU) Fall 2022 and atended Fall 2022, Spring 2023, and Summer 2023. The student s􀆟ll had Pell eligibility remaining to be awarded Pell Grant at MU for Summer 23, but there was a rounding issue (PowerFAIDS rounds up) and this caused a POP (Poten􀆟al Pell Overpayment) situa􀆟on with MU and the prior university. The adjustment was processed outside of the required 􀆟meframe with COD; however, the award amounts were appropriately addressed and corrected. This is a unique situa􀆟on and happens rarely. The Office of Financial Aid will review more carefully when awarding Pell Grant for rounding issues. Anticipated Completion Date: December 15, 2023

View Audit 291593

Finding 370075 (2023-002)

None 2023

The Methodist University, Inc.

NC

Student Financial Aid Special Tests & Provisions Subrecipient Monitoring

Contact Person: Kasi Turner, Registrar Corrective Action: We manually reported a student as withdrawn on 2/17/2023. The status change came in as an error on the 3/16/2023 submission (the following month) and we manually updated the status and status start date for the student again. However, it loo...

Contact Person: Kasi Turner, Registrar Corrective Action: We manually reported a student as withdrawn on 2/17/2023. The status change came in as an error on the 3/16/2023 submission (the following month) and we manually updated the status and status start date for the student again. However, it looks like the student’s status reverted to Three-Quarter time on the final transmission on 5/1/2023. We will commit to closer monitoring of withdrawals submitted manually by our office on subsequent enrollment transmissions through the Clearinghouse. Anticipated Completion Date: December 15, 2023

View Audit 291593

Finding 370073 (2023-001)

Significant Deficiency 2023

La Pine Community Health Center

OR

Allowable Costs / Cost Principles

U.S. Department of Health and Human Services La Pine Community Health Center respectfully submits the following corrective action plan for the year ended October 31, 2023. Audit period: November 1, 2022 – October 31, 2023 The findings from the schedule of findings and questioned costs are discussed ...

U.S. Department of Health and Human Services La Pine Community Health Center respectfully submits the following corrective action plan for the year ended October 31, 2023. Audit period: November 1, 2022 – October 31, 2023 The findings from the 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 noted. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2023-001 Health Center Program Cluster – Assistance Listing No. 93.224, 93.527 Recommendation: CLA recommends that La Pine Community Health Center retain documentation and records for expenditures allocated to federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will design and implement procedures to perform checks and review allocated expenditures to ensure proper documentation is retained. Name(s) of the contact person(s) responsible for corrective action: Karen Forman, CFO Planned completion date for corrective action plan: October 31, 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Karen Forman, CFO, at 541-876-1843.

View Audit 291587

Finding 370066 (2023-002)

Significant Deficiency 2023

Alexander Youth Network

NC

Reporting Subrecipient Monitoring § 200.329

Identifying Number: 2023-002 Finding: For 2 out of the 8 reports selected for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program, the reports were not submitted within the required timeframe. For 3 out of the 8 reports selected, there was no evidence of submission. For 2 out o...

Identifying Number: 2023-002 Finding: For 2 out of the 8 reports selected for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program, the reports were not submitted within the required timeframe. For 3 out of the 8 reports selected, there was no evidence of submission. For 2 out of the 5 reports selected for the Transitional Living for Homeless Youth program, the reports were not submitted within the required timeframe. For 2 out of the 5 reports selected for the Basic Grant program, the reports were not submitted within the required timeframe. Corrective Action Plan for Audit Finding 2023-002: Calendar reminders will be created for both financial and performance reports. Director Finance & Business will follow up with the program for the status of performance report submissions. Chief of Staff, The Relatives will maintain a PDF of performance report submission emails. Responsible for Corrective Action Plan: Julie Pool, Director of Finance & Business, Program Director, Youth Focus and Chief of Staff, The Relatives

View Audit 291571

Finding 370064 (2023-001)

None 2023

Alexander Youth Network

NC

Allowable Costs / Cost Principles § 200.403

Identifying Number: 2023-001 Finding: For 3 out of the 26 transactions selected for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program, the expenditures were recorded for an inaccurate amount. For 1 out of 25 transactions selected for the Transitional Living for Homeless Youth...

Identifying Number: 2023-001 Finding: For 3 out of the 26 transactions selected for the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program, the expenditures were recorded for an inaccurate amount. For 1 out of 25 transactions selected for the Transitional Living for Homeless Youth program, the expenditure was not accrued in the appropriate fiscal year in accordance with U.S. GAAP. Corrective Action Plan for Audit Finding 2023-001: The first item above related to rental payment. Incorrect payment made due to incorrect information/approval from the program. An additional level of lease review by Director of Finance and Business added to confirm payment matches lease upon initiation of new leases and lease renewals. The second item above related to a gas card account. The Director of Finance & Business and Director of Accounting have discussed this. An item added to year-end/audit check list to review October statement and identify/accrue any expenses incurred on or prior to September 30. Responsible for Corrective Action Plan: Julie Pool, Director of Finance & Business

View Audit 291571

Finding 370061 (2023-001)

Significant Deficiency 2023

The House of Hope, Inc.

FL

Federal Program: Block Grants for Prevention and Treatment of Substance Abuse ‐ 93.959 2023-001: Year End Closing Schedule – Timely Reconciliations: Criteria: Timely preparation of account reconciliations is essential to producing accurate and relevant financial reports. Condition: During the audit ...

Federal Program: Block Grants for Prevention and Treatment of Substance Abuse ‐ 93.959 2023-001: Year End Closing Schedule – Timely Reconciliations: Criteria: Timely preparation of account reconciliations is essential to producing accurate and relevant financial reports. Condition: During the audit a number of adjusting journal entries were proposed by both the audit team and management. These entries were to adjust errors or to reflect year‐end accruals. Cause: Existing closing procedures should be reviewed and updated to ensure that they are properly followed in producing timely reports and reducing year‐end adjustments. Effect: The results were delays in producing reconciliations, account analyses and other financial reports needed by management and the auditors. Recommendation: We believe that the year‐end closing could proceed more quickly by incorporating a closing schedule that indicates who will perform each procedure and when completion of each procedure is due and accomplished. The timing of specific procedures could be coordinated with the timing of management’s or the auditor’s need for information. All reconciliations should be prepared and reviewed by those informed of such matters to ensure accuracy. Current status: During the year ending June 30, 2023, the Organization made significant improvements in its implementation of closing procedures. However, due to limited staffing resources the Organization should continue to improve the accuracy and execution of such procedures. Management Response: Management Response: As a result of our growth and increased budget, we approved an additional finance staff person at the October 2023 Board meeting. We are currently using a temporary employee while we hire. In addition, we have moved our investments to an investment firm to make coordination of information easier and more readily available. We have created a centralized file system to store audit documentation as it is available during the year and enhanced our closing checklist.

View Audit 291569

Finding 370060 (2023-002)

Significant Deficiency 2023

Trenton Housing Authority

TN

HUD Housing Programs Internal Control / Segregation of Duties

Finding #2023-002 - Finding Description - Waiting List for Public Housing Corrective Action Plan: Management will keep a copy of the waiting list as new tenants are housed. Anticipated Completion Date: In Process beginning 1/24/2024 Contact Person: Doug Lockard, Executive Director 128 Burnett Drive,...

Finding #2023-002 - Finding Description - Waiting List for Public Housing Corrective Action Plan: Management will keep a copy of the waiting list as new tenants are housed. Anticipated Completion Date: In Process beginning 1/24/2024 Contact Person: Doug Lockard, Executive Director 128 Burnett Drive, Trenton, TN 38382 (731) 855-1231

View Audit 291566

Finding 370056 (2023-001)

Material Weakness 2023

Lamoille County Mental Health Services, Inc.

VT

Questioned Costs Eligibility Special Tests & Provisions

Recommendation:Lamoille County Mental Health Services, Inc. should put procedures in place to make sure that that they are in compliance with grant agreements and that all expenditures fall within the proper granting period. Action Taken: Lamoille County Mental Health Services, Inc. was able to rep...

Recommendation:Lamoille County Mental Health Services, Inc. should put procedures in place to make sure that that they are in compliance with grant agreements and that all expenditures fall within the proper granting period. Action Taken: Lamoille County Mental Health Services, Inc. was able to replace the ineligible expenditures from wages paid in December 2021 to qualifying wages paid in January 2023. If U.S. Department of Health and Human Services has any questions regarding this plan, please call Jeff Kellar at (800) 301,3624 ext. 3624.

View Audit 291564 Questioned Costs: $1

Finding 370050 (2023-001)

Significant Deficiency 2023

Lawrence University of Wisconsin

WI

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

Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend that management review the process for ensuring the accuracy of the program effective date for students with changes in status within the NSLDS system. Explanation of disagreement with audit fin...

Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268 Recommendation: We recommend that management review the process for ensuring the accuracy of the program effective date for students with changes in status within the NSLDS system. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The registrar’s office worked with Technology Services to review the National Student Clearinghouse data extract from Banner for the applicable term. Although the file aligned with previous submissions to National Student Clearinghouse, a fix was made for the Lawrence custom extract. The midyear 2023 grad file was run against the updated code and the extract looks as the auditors would expect. This should result in a program effective date equivalent to end date of student's final term for all Lawrence graduates in future submissions. Name of the contact person responsible for corrective action: Angi Long, Registrar Planned completion date for corrective action plan: 2/1/2024

View Audit 291560

Finding 370049 (2023-009)

Material Weakness 2023

Lebanon Community Unit School District 9

IL

Procurement, Suspension & Debarment Subrecipient Monitoring

Management agrees and will implement procedures to verify and ensure all vendors have not suspended or debarred prior to doing business with the entity.

View Audit 291559

Finding 370048 (2023-008)

Material Weakness 2023

Lebanon Community Unit School District 9

IL

Equipment & Real Property Management Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.313

Management will develop internal control procedures for tracking fixed assets purchased with federal funds to ensure the District is complying with the Equipment and Real Property compliance requirement.

View Audit 291559

Finding 370047 (2023-007)

Material Weakness 2023

Lebanon Community Unit School District 9

IL

The District will implement proper controls to ensure all federal revenues and expenditures are recorded on its general ledger.

View Audit 291559

Finding 370045 (2023-006)

Material Weakness 2023

Lebanon Community Unit School District 9

IL

Equipment & Real Property Management Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.313

Management will develop internal control procedures for tracking fixed assets purchased with federal funds to ensure the District is complying with the Equipment and Real Property compliance requirement.

View Audit 291559

Finding 370043 (2023-005)

Material Weakness 2023

Lebanon Community Unit School District 9

IL

Management will reinforce procedures to gather the required information for the reports and set reminders to ensure that they will be filed in a timely manner.

View Audit 291559

Corrective Action Plans

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