Corrective Action Plans

Finding 10659 (2023-002)

Material Weakness 2023

MI

Questioned Costs Special Tests & Provisions Procurement, Suspension & Debarment

Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Three o...

Finding: 2023-002 – Special Tests and Provisions – Wage Rate Requirements U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Three of the contracts selected for testing that were subject to the Wage Rate Requirements did not include the required provision, and the District did not obtain the required certified payrolls. The District did not follow federal requirements to include the prevailing wage rate provision in its contract. Auditor Recommendation: We recommend that the District reviews its policies to ensure that applicable prevailing wage requirements are included in construction contracts whenever federal funds are used and certified payrolls are obtained. Corrective Action: District officials will ensure that construction contracts contain these requirements during the bidding and/or proposal process. Responsible Person: Rebecca Jones, Superintendent and Tara Newman, Business Manager Anticipated Completion Date: June 30, 2024

View Audit 14327 Questioned Costs: $1

Finding 10656 (2023-001)

Significant Deficiency 2023

Marshall Public Schools

MI

Allowable Costs / Cost Principles

Finding: 2023-001 – Allowable Costs/Cost Principles – Timesheets U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two out of forty...

Finding: 2023-001 – Allowable Costs/Cost Principles – Timesheets U.S. Department of Education – COVID-19 - Education Stabilization Fund (ALN 84.425D and 84.425U); Passed through the Michigan Department of Education; All project numbers. Auditor Description of Condition and Effect: Two out of forty disbursements selected for testing did not include the required documentation by the employee and approvals by their supervisor. As a result of this condition, the District was exposed to increased risk that payroll charges of federal awards could be made for unallowable costs. Auditor Recommendation: We recommend that the District review its written policies and procedures over federal awards to ensure that all timesheets have the appropriate documentation and evidence of review and approval prior to payment. Corrective Action: The business office will be reviewing that all timesheets are signed by employees and approved by their supervisor prior to payment. Responsible Person: Rebecca Jones, Superintendent and Tara Newman, Business Manager Anticipated Completion Date: June 30, 2024

View Audit 14327

Finding 10633 (2023-001)

Significant Deficiency 2023

Brewton-Parker College

GA

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking § 200.303

Finding 2023-001: Special Tests and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, 3 students within the sample were reported to NSLDS outside the maximum 60-day window. Recommendation: The auditor recommended that the College rev...

Finding 2023-001: Special Tests and Provisions: Enrollment Reporting Context/Condition: Of the 40 students selected for enrollment reporting testing, 3 students within the sample were reported to NSLDS outside the maximum 60-day window. Recommendation: The auditor recommended that the College review and update internal controls to ensure student enrollment status in the National Student Loan Data System (NSLDS) is updated in a timely manner to ensure compliance with Federal requirements. Persons Responsible for Corrective Action: Dr. Deokhyo Kim, Registrar Planned Corrective Action: We communicated with our software vendor, Aptron, to determine what caused the enrollment reporting issues. We identified two issues and worked with Aptron to put measures in place so that these issues do not happen in the future. 1. Missing withdrawn students who were not pulled up by system when they withdrew before or on the 1st enrollment report date. APTRON fixed the programming and the system now pulls those who are withdrawn before or on the 1st enrollment report date for each semester. 2. Missing graduates with their 2nd degree. APTRON fixed the programming, so that our Degree Verify file will now report a student who has earned a second degree with us. A Degree Verify File of graduates was submitted to the NSCH for any student who had earned a second degree not previously reported. Anticipated Completion Date: Fixes with our software vendor have been completed.

View Audit 14308

Finding 10553 (2023-003)

Significant Deficiency 2023

Pojoaque Valley School District

NM

Special Tests & Provisions

2023-003 Lack of Control over Compliance The district will work on creating a procedure on performing the required calculation for the Impact Aid Program and will seek assistance if needed to rectify this finding. The program manager will research the calculation that need to be performed in the 23-...

2023-003 Lack of Control over Compliance The district will work on creating a procedure on performing the required calculation for the Impact Aid Program and will seek assistance if needed to rectify this finding. The program manager will research the calculation that need to be performed in the 23-24 school year to ensure proper compliance for this fund in the future.

View Audit 14275

Finding 10541 (2023-001)

Significant Deficiency 2023

Boulder Valley School District Re-2

CO

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

BOULDER VALLEY SCHOOL DISTRICT CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 Boulder Valley School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and ques...

BOULDER VALLEY SCHOOL DISTRICT CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 Boulder Valley School District respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 COVID-19 – Education Stabilization Fund – Assistance Listing No. 84.425U Recommendation: We recommend the District add a review process into their controls to ensure all employees’ time being charged to the grant is accurately captured. Additionally, we recommend the District review and adjust all final time and effort certifications in a timely manner, based on the final adjusted and allowable personnel expenditures charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will take the following actions in response to the finding:  Missing time and effort certifications have been obtained from the 3 employees.  Adjustments will be made to ensure the grant is charged the correct amount of eligible personnel costs.  To align with the timing of semi-annual time and effort certifications in December and June each year, the District will implement the following procedures in February and September, related to each preceding 6-month period: o Review personnel costs charged to each grant on an employee-by-employee basis to ensure the amount charged to the grant is accurate. o Review time and effort certifications for all employees, compared to the final actual personnel costs charged to each grant.  Assess and implement functionality in the Infor ERP system to: o Maintain time and effort records and have employees certify their time within the Infor ERP system. This process is currently manual and outside of the ERP system. o Develop, test and implement grant reporting capabilities in the Infor ERP system, to assist in monitoring all District grants. Efforts to date with Infor consultants to develop grant reports have not achieved the desired results. Current reports must be manually generated. Name of the contact person responsible for corrective action: Bill Sutter, CFO Planned completion date for corrective action plan: September 2024 If the Colorado Department of Education has questions regarding this plan, please call Bill Sutter, CFO at 720-561-5019.

View Audit 14270 Questioned Costs: $1

Finding 10540 (2023-002)

Significant Deficiency 2023

The Housing Authority of the County of Kern

CA

Internal Control / Segregation of Duties Special Tests & Provisions

Comments on the Finding and Each Recommendation: Management agrees with both the finding and the recommendations. Action(s) Taken or Planned on the Finding Under the direction of the Assistant Executive Director, the Housing Administrator has already established an inspection oversight process with ...

Comments on the Finding and Each Recommendation: Management agrees with both the finding and the recommendations. Action(s) Taken or Planned on the Finding Under the direction of the Assistant Executive Director, the Housing Administrator has already established an inspection oversight process with HQS staff addressing the deficiencies noted in the finding, including the timeliness of reinspection. The process also includes implementing an updated voucher abatement and loss procedure before 12/31/2023. The operations memorandum detailing the oversight process will be distributed to staff before 01/01/2024.

View Audit 14268

Finding 10539 (2023-002)

Significant Deficiency 2023

Lafourche Parish School Board

LA

Cash Management Reporting Internal Control / Segregation of Duties

The district will adjust its operations to include a financial review and reconciliation of the reimbursement requests prepared on its behalf by the private consultant administering the program.

View Audit 14264

Finding 10538 (2023-001)

Significant Deficiency 2023

Lafourche Parish School Board

LA

Procurement, Suspension & Debarment § 200.320

The Business Department will review the Uniform Guidance requirements with all grant administrators and procurement staff to ensure compliance with federal regulations and district policy; and it will establish a more thorough review process for contracts to ensure compliance with all requirements.

View Audit 14264

Finding 10533 (2023-004)

Significant Deficiency 2023

Isd #2856 Stephen/argyle

MN

Cash Management

Contact Person – Drew Kjono, Superintendent; Corrective Action Plan – The District will implement controls to ensure all reports submitted for reimbursement, only contain actual grant expenditures.; Completion Date – January 31, 2024

View Audit 14251

Finding 10532 (2023-003)

Significant Deficiency 2023

Isd #2856 Stephen/argyle

MN

Cash Management Reporting

Contact Person – Drew Kjono, Superintendent; Corrective Action Plan – The District will establish policy to review the supporting documentation for reimbursement reports.; Completion Date – January 31, 2024

View Audit 14251

Finding 10531 (2023-002)

Significant Deficiency 2023

Village Cooperative of the Northland

MO

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

The Cooperative will make required deposits to the General Operating Reserve.

View Audit 14220

Finding 10530 (2023-001)

Significant Deficiency 2023

Village Cooperative of the Northland

MO

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.

View Audit 14220

Finding 10529 (2023-001)

Significant Deficiency 2023

Village Cooperative of Red Wing

MN

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.

View Audit 14217

Finding 10512 (2023-001)

Significant Deficiency 2023

Village Cooperative of Austin

MN

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative. The Cooperative hired a new management agent with proper segregation of duties.

View Audit 14215

Finding 10508 (2023-004)

Significant Deficiency 2023

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO de...

Finding 2023.004 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken Health contracted with an interim Chief Financial Officer in January 2023. The interim CFO departed in February 2023 and was unable to provide the organization with work source documents for the 2022 UDS submission. Effective January 2024, the current Chief Financial Officer and the electronic medical records specialist (IT) will ensure all source documentation for the UDS submission is saved on the organization’s shared file drive to support the annual UDS submission.

View Audit 14201

Finding 10504 (2023-003)

Significant Deficiency 2023

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Subrecipient Monitoring Allowable Costs / Cost Principles HUD Housing Programs

Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Heal...

Finding 2023.003 - Activities Allowed or Unallowed Recommendation The Organization should establish a system of internal controls to ensure that all employees are being paid the correct amounts. Action Taken United Methodist Western Kansas Mexican-American Ministries Inc. d/b/a Genesis Family Health implemented PayCom in January 2023. With this system update, the organization has implemented an automated process to ensure changes to employee pay rates are approved and adjusted timely. This process requires all changes to employee’s compensation being entered into the PayCom (payroll system) by the departmental managers/supervisors. Changes in pay are automatically flagged for review and approval by the human resources department. These changes improved internal controls to ensure all employee rate changes are implemented timely and employees are being paid the correct amount.

View Audit 14201

Finding 10500 (2023-002)

Significant Deficiency 2023

United Methodist Western Kansas Mexican American Ministries Inc. D/b/a Genesis Family Health

KS

Subrecipient Monitoring Eligibility HUD Housing Programs

Finding 2023.002 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken The proficiency of all billing staff respon...

Finding 2023.002 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken The proficiency of all billing staff responsible for applying sliding fee discounts and ensuring proper calculations based on family size and income will be evaluated. The organization implemented an Onboarding and Enrollment department in June 2023 to review clinic schedules prior to the patient’s appointment. The onboarding and enrollment staff meet with each new patient to review and verify insurance information, check Medicaid eligibility, ensure fully completed registrations and complete application for any slide fee discounts applicable based on income and family size. Billing staff reviews this information and applies the appropriate discount to the patient charges. This crosschecking process will improve internal controls related to the sliding fee discount process.

View Audit 14201

Finding 10499 (2023-002)

Significant Deficiency 2023

Payne Theological Seminary

OH

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend that the Seminary review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The seminary will update our current WISP to comply with additional requirements and newer standards. Name(s) of the contact person(s) responsible for corrective action: Raymond Ingram, Director of Finance Planned completion date for corrective action plan: February 1,2024

View Audit 14195

Finding 10498 (2023-001)

Significant Deficiency 2023

Payne Theological Seminary

OH

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

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS...

Student Financial Aid Cluster – CFDA No. 84.268 Recommendation: We recommend the Seminary reevaluate its procedures and review policies surrounding reporting status changes to NSLDS to ensure timely reporting as well as put a process in place to ensure the enrollment effective date reported to NSLDS is aligning with the Seminary's last date of attendance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Seminary will continue to use the import / export function to report to NSLDS. Financial Aid Services will reiew the report, prior to submission, for any errors, duplications, etc. Name(s) of the contact person(s) responsible for corrective action: Maryjo Lewis, Registar Planned completion date for corrective action plan: January 1,2024

View Audit 14195

Finding 10484 (2023-001)

Significant Deficiency 2023

Volunteers of America Northern Rockies

WY

Eligibility Subrecipient Monitoring Significant Deficiency

Condition: In a monitoring visit performed by the U.S. Department of Labor, the grantor found that service coordinators are verifying that the veterans meet the “Homelessness” requirement to be enrolled in the program, but in some instances, were missing the verification (case notes or form entries)...

Condition: In a monitoring visit performed by the U.S. Department of Labor, the grantor found that service coordinators are verifying that the veterans meet the “Homelessness” requirement to be enrolled in the program, but in some instances, were missing the verification (case notes or form entries) and relying on self-attestation, which should be a last resort. Planned Corrective Action: The Organization responded to the monitoring visit recommendation referenced by providing additional staff training and implementing a verification function to ensure all applicable case notes, form entries, and documentation are acquired and made part of the case file. Contact person responsible for corrective action: Craig Fisgus, Vice President of Veteran Services Anticipated Completion Date: Revised processes were implemented immediately following the receipt of the monitoring visit recommendation.

View Audit 14170

Finding 10477 (2023-002)

None 2023

Silver Lake Joint #1 School District

WI

Internal Control / Segregation of Duties

Management Response - The District Superintendent and Business Manager review and approve the financial statements. Upon completion of the full audit, the school board reviews, comments on, and approves the audited financial statements.

View Audit 14165

Finding 10476 (2023-001)

None 2023

Silver Lake Joint #1 School District

WI

Internal Control / Segregation of Duties

Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of indiv...

Management Response – Because of the size of the office and the district, we are precluded from maintaining a proper staff size to ensure a proper segregation of duties. We are aware of this condition, and we realize that the concentration of duties and responsibilities in a limited number of individuals in not desirable for an effective system of internal control. To mitigate the issue of lack of segregation of duties, we have cross trained virtually each of the business office employees. While we do have a dedicated payroll person, another individual will perform cross checks & verifications independently. The same goes for issuing checks, accounts receivable, accounts payable, and activity funds. These functions are overseen by the business manager.

View Audit 14165

Finding 10472 (2023-002)

Significant Deficiency 2023

Mt. Hood Community College

OR

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

Christopher Natelborg (Director of Financial Aid) and Dawn Sallee-Justesen (Director of Enrollment Services) will implement the following procedures and internal controls to ensure accurate dates are reported to NSLDS that agree with District records: • For NSLDS Enrollment Reporting purposes, 34 CF...

Christopher Natelborg (Director of Financial Aid) and Dawn Sallee-Justesen (Director of Enrollment Services) will implement the following procedures and internal controls to ensure accurate dates are reported to NSLDS that agree with District records: • For NSLDS Enrollment Reporting purposes, 34 CFR 685.305(c) requires schools to report the same withdrawal date that the school used for the return of Title IV funds (R2T4) purposes under 668.22(b) or (c). That is, the effective date for the withdrawn (‘W’) status is the withdrawal date used by the school in the R2T4 calculation. To ensure reporting is accurate, the Office of Financial Aid will communicate to the Registrar the specific student files and the dates of withdrawal used for any unofficial withdrawal R2T4 calculations after each term and the Registrar will update the student’s date of withdrawal on file with NSLDS within the required enrollment reporting deadlines. • The Director of Financial Aid and Director of Enrollment Services will also explore Information Technology automating the unofficial withdrawal date reporting to NSLDS. These corrective actions will be implemented by February 2024, including updating the dates in NSLDS for the 2023 summer and fall term unofficial withdrawals.

View Audit 14137

Finding 10471 (2023-001)

Significant Deficiency 2023

Rogers Behavioral Health System, Inc.

WI

Questioned Costs Internal Control / Segregation of Duties

Rogers Behavioral Health System, Inc. and Subsidiaries CORRECTIVE ACTION PLAN YEAR ENDED July 31, 2023 Identifying Number: 2023-001 Finding: In the internal tracking of eligible COVID-19 related expenses applied to the Period 4 PRF receipts for Rogers Behavioral Health System, Inc. and Subsidiari...

Rogers Behavioral Health System, Inc. and Subsidiaries CORRECTIVE ACTION PLAN YEAR ENDED July 31, 2023 Identifying Number: 2023-001 Finding: In the internal tracking of eligible COVID-19 related expenses applied to the Period 4 PRF receipts for Rogers Behavioral Health System, Inc. and Subsidiaries (the Health System), the Health System calculated invoice amounts related to legal services incurred as part of the Health System’s response to COVID-19 in a manner that increased legal expenses applied to PRF funds by the percent discount given by legal counsel rather than decreasing legal expenses applies to PRF funds. Calculating the identified eligible legal expenses in this manner occurred for legal expenses incurred and applied to PRF funds from August 2021 to February 2022. Additionally, for one month, the Health System included the eligible expenses twice in the internal tracking of eligible COVID-19 related expenses. Corrective Actions Taken or Planned: Rogers ensured there were enough valid qualifying expense to support the funds received. Future assignments of costs will be reviewed for reasonableness and appropriateness to ensure only proper allowable costs are submitted to support funds received. This will be achieved by the utilization of work tag assignments on allowable costs. Due to a recent financial system implementation, Rogers will be able to use enhanced tools to track costs more accurately. Person Responsible: Emily Russart, Controller Anticipated Completion Date: March 31, 2024

View Audit 14135 Questioned Costs: $1

Finding 10466 (2023-002)

Significant Deficiency 2023

Franklin Parish School Board

LA

Procurement, Suspension & Debarment § 200.318 § 200.326

Sheila Nolan, Child Nutrition Supervisor, acknowledges the finding regarding the purchase of produce products for SY 2022-23. There is only one regional produce distributor that successfully delivers to the Franklin Parish area with accurate invoices and timely deliveries based on past history. Due ...

Sheila Nolan, Child Nutrition Supervisor, acknowledges the finding regarding the purchase of produce products for SY 2022-23. There is only one regional produce distributor that successfully delivers to the Franklin Parish area with accurate invoices and timely deliveries based on past history. Due to staff changes and re-assignment of essential job functions, the produce bid was overlooked for this this year only. Moving forward, the CNP Supervisor has established a procurement schedule for developing and revising necessary formal bids in compliance with Federal and State requirements and all CNP central office staff. During SY 2022-23, the Franklin Parish Child Nutrition Program experienced multiple shortages of canned and frozen vegetables and fruits. This made it essential to fill in with fresh produce to meet meal pattern requirements. This created a marked increase in the cost of the fresh produce available to us and increased our reliance on fresh produce.

View Audit 14128

Corrective Action Plans

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