Corrective Action Plans

Finding 9570 (2023-002)

Significant Deficiency 2023

OR

HUD Housing Programs Eligibility Significant Deficiency

2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement wi...

2023-002 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their policies to ensure all required documentation is maintained for all individuals who are on the waiting list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: NOHA has reviewed its policies regarding documentation maintenance for all individuals on the waiting list. Quality control review of waiting list data entry was put in place after October 2020. The oldest application on the current HCV waiting list is dated 2019. NOHA anticipates this finding may continue until the waiting list application dates reach 10/2020. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

View Audit 13226

Finding 9568 (2023-001)

Significant Deficiency 2023

Northwest Oregon Housing Authority

OR

Questioned Costs HUD Housing Programs Eligibility

2023-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: T...

2023-001 Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: The Authority should review their processes for eligibility determination and documentation to ensure all information is properly documented and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Northwest Oregon Housing Authority has reviewed eligibility determination and documentation processes. Staff have received updated training regarding proper data entry of assets and application of COLA. NOHA continues to conduct on-going quality control file reviews to monitor file quality; year to date, approximately 6.5% of transactions have been reviewed. Name(s) of the contact person(s) responsible for corrective action: Sandra Soucie, HCV Manager, HCVManager@nwoha.org Planned completion date for corrective action plan: 1/31/2024

View Audit 13226 Questioned Costs: $1

Finding 9535 (2023-001)

None 2023

Berkshire County Head Start Child Development Program, Inc.

MA

Internal Control / Segregation of Duties § 200.512

Finding No. 2023-001 Late Filing of Audit Package and Data Collection Form Description of Finding: The audit package and data collection form were not filed with the FAC within the required timeframe for the year ended February 28, 2023. Statement of Concurrence: Berkshire County Head Start Child De...

Finding No. 2023-001 Late Filing of Audit Package and Data Collection Form Description of Finding: The audit package and data collection form were not filed with the FAC within the required timeframe for the year ended February 28, 2023. Statement of Concurrence: Berkshire County Head Start Child Development Program, Inc. concurs with the audit finding. Corrective Action: Berkshire County Head Start Child Development Program, Inc. has replaced the finance director who left during the audit that resulted in the delay. Name of Contact Person: lvania Mottos, Finance Manager, imottos@berkhs.org Projected Completion Date:Immediate - the position of the finance director has since been filed and the Organization does not expect any such delays in the future.

View Audit 13193

Finding 9533 (2023-001)

None 2023

Sterling High School District

NJ

School Nutrition Programs

Recommendation Number - 2023-001 Correction Action - Develop a plan to reduce the food service fund’s net cash resources below its three (3) month average expenditures. Method of Implementation - Monitor net cash resources. Work with cafeteria staff and administration to identify and create plan ...

Recommendation Number - 2023-001 Correction Action - Develop a plan to reduce the food service fund’s net cash resources below its three (3) month average expenditures. Method of Implementation - Monitor net cash resources. Work with cafeteria staff and administration to identify and create plan to use funds on allowable purchases to reduce net cash. Responsible for Implementation - Mr. Matt Sheehan, Superintendent Estimated Completion Date - March 2024, ongoing

View Audit 13192

Finding 9524 (2023-002)

Significant Deficiency 2023

Carbon County School District #1

WY

Subrecipient Monitoring Reporting

Name of Contact Person – Margaret Quintrall, Business Manager Corrective Action Carbon County School District #1 established a district folder for information used to complete all state and federal reporting requirements. Proposed Completion Date: July 5, 2023

View Audit 13186

Finding 9519 (2023-002)

Material Weakness 2023

Crockett County Consolidated Common School District

TX

Internal Control / Segregation of Duties Reporting

Recommendation: The general ledger should be reviewed for completeness and accuracy, bank accounts should be reconciled, expenditures should be monitored to assure that they are within the budget and any necessary corrections should be made in a timely manner. Action Taken: The District will impl...

Recommendation: The general ledger should be reviewed for completeness and accuracy, bank accounts should be reconciled, expenditures should be monitored to assure that they are within the budget and any necessary corrections should be made in a timely manner. Action Taken: The District will implement procedures to ensure that the District’s personnel review the general ledger and make necessary adjustments when needed. Additional staff or outside assistance will be engaged as needed. Anticipated Completion Date: Throughout Fiscal Year Ending August 31, 2024

View Audit 13168

Finding 9515 (2023-002)

Material Weakness 2023

Iraan-Sheffield Collegiate Independent School District

TX

Internal Control / Segregation of Duties Reporting

Recommendation: The general ledger should be reviewed for completeness and accuracy, and any necessary corrections should be made in a timely manner. Expenditures should be monitored to assure that they are within the budget. Action Taken: The District will implement procedures to ensure that th...

Recommendation: The general ledger should be reviewed for completeness and accuracy, and any necessary corrections should be made in a timely manner. Expenditures should be monitored to assure that they are within the budget. Action Taken: The District will implement procedures to ensure that the District’s personnel review the general ledger and make necessary adjustments and budget amendments as needed. Additional staff or outside assistance will be engaged as needed. Anticipated Completion Date: Throughout Fiscal Year Ending August 31, 2024

View Audit 13163

Finding 9514 (2023-006)

None 2023

Grant County

OR

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.516

Views of responsible officials and planned corrective actions: The County does not have available funding to hire a grant compliance officer, however, the County plans to seek training resources for current staff responsible for grant administration

View Audit 13148 Questioned Costs: $1

Finding 9513 (2023-005)

Material Weakness 2023

Grant County

OR

Material Weakness Reporting Internal Control / Segregation of Duties

Views of responsible officials and planned corrective actions: A County Court member will meet with the contractor providing Title III services to discuss corrective action regarding timely completion of reporting and meeting reporting requirements

View Audit 13148

Finding 9509 (2023-001)

Significant Deficiency 2023

Heartland Medical Clinic, Inc., D/b/a Heartland Community Health Center

KS

Subrecipient Monitoring Eligibility HUD Housing Programs

To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 3...

To United States Department of Health and Human Services Heartland Community Health Center respectfully submits the following corrective action plan for the year ended April 30, 2023. CohnReznick, LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2023 The findings from the April 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Awards Findings: Finding 2023.001 - Sliding Fee Scale Discount 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 • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2024. Any findings through the audit process will be reported to the COO. At least five patien.t charts will be audited monthly. o In addition, the billing manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper set up of sliding fee discounts. o Health Center Practice Administrator will review and implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and billing manager. If there are any question regarding this plan, please e-mail Regina Oxford at roxford@heartlandhealth.org. Sincerely,

View Audit 13129

Finding 9508 (2023-001)

Significant Deficiency 2023

Dima Iv, Inc.

DE

HUD Housing Programs

Senior Director of Housing and Facilities will process monthly HAP reports for HUD projects. Upon completion, Senior Director of Finance for NAMI Delaware will review HAP reports to ensure that the Contract Rent (9.) and Gross Rent (11.) match the authorized amount set by HUD.

View Audit 13122

Finding 9505 (2023-001)

Significant Deficiency 2023

Hendrix College

AR

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

January 19, 2024 Department of Education Corrective Action Plan for Finding 2023-001 Hendrix College concurs with audit finding related to missing MPN documents under the Perkins Loan program as a repeat finding (previously 2022-002). The College offers the corrective actions as outlined below. For ...

January 19, 2024 Department of Education Corrective Action Plan for Finding 2023-001 Hendrix College concurs with audit finding related to missing MPN documents under the Perkins Loan program as a repeat finding (previously 2022-002). The College offers the corrective actions as outlined below. For any further questions or requests for further information, please contact Mr. Shawn Mathis, Associate VP and Controller for the College at 501-450-1474, or email mathis@hendrix.edu In response to Reference Number: 2022-002, In April 2023 the college performed an inventory of all documents onsite in the designated file cabinets related to Perkins loans. That information has been updated subsequent to May 31, 2023, to include all documents that exist electronically. Below is a summary of our findings as of November 30, 2023. As of November 30, 2023, there are 220 active Perkins Loans with balances greater than zero. Below is a summary of the loans. We were able to locate 182 (83%) of the loans Master Promissory Notes (“MPN”), with management unable to find the MPN for the remaining 38. Signed MPN 182 82.73% No MPN on file 38 220 For the 38 loans that the college did not have the MPN, were researched further to determine that 30 of those accounts contained student-initiated activity that substantiates the debt and the remaining eight loans will be purchased by the College for collection.

View Audit 13102

Finding 9492 (2023-001)

Material Weakness 2023

Boys and Girls Village, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

The VP of Finance will make a template to reconcile A/R to Carelogic. On monthly basis the new senior accoutant will use this template to reconcile A/R to Carelogic. VP of Finance will review and sign off monthly.

View Audit 13073

Finding 9485 (2023-001)

Significant Deficiency 2023

Santa Paula Unified School District

CA

Questioned Costs Allowable Costs / Cost Principles

For the 2022-23 School Year, the District failed to correctly allocate expenditures to the CACFP accounts. In order to correct this action for the 2023-24 school year, the Director of Fiscal services will work with the Director of Child nutrition to reconcile each program and complete the cost alloc...

For the 2022-23 School Year, the District failed to correctly allocate expenditures to the CACFP accounts. In order to correct this action for the 2023-24 school year, the Director of Fiscal services will work with the Director of Child nutrition to reconcile each program and complete the cost allocation worksheet. The District utilizes a direct cost vending agreement, which will allocate the costs in an allowable manner. The Director of Fiscal Services will be responsible for making the transfer of expenditures from NSLP accounts to the CACFP accounts. The Director of Child Nutrition will verify the transfers have been completed correctly before the books are closed

View Audit 13071 Questioned Costs: $1

Finding 9481 (2023-001)

Significant Deficiency 2023

Santa Fe County

NM

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June ...

Corrective Action Plan: The Finance Division will add calendar reminders to confirm all subsequent reporting on the audited financial statements and federal grants are completed by the various deadlines. Person Responsible: Yvonne Herrera, Finance Division Director Estimated Completion Date: June 30, 2024

View Audit 13026

Finding 9480 (2023-001)

None 2023

Upper Explorerland Regional Housing Authority

IA

Recommendation: While we do recognize that mistakes can and will happen, we recommend that tenant files are reviewed before finalizing to ensure that all forms are included to verify compliance with grant guidelines. Action Taken: We agree with the auditor and will take under advisement. ...

Recommendation: While we do recognize that mistakes can and will happen, we recommend that tenant files are reviewed before finalizing to ensure that all forms are included to verify compliance with grant guidelines. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: June 30, 2024

View Audit 13023

Finding 9474 (2023-002)

Significant Deficiency 2023

Bevill State Community College

AL

Special Tests & Provisions Student Financial Aid Significant Deficiency

Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly pr...

Corrective Action Plan: Management is in the process of updating Policies and Procedures to help ensure that calculations are run correctly and timely. The Financial Aid office and the Finance Office will work together each semester to ensure Banner setup is correct, updated, and working properly prior to any calculations being performed. Anticipated Completion Date: January 31, 2024

View Audit 12991

Finding 9471 (2023-001)

Material Weakness 2023

Lancaster City School District

OH

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

District Administration was originally made aware of the specific requirements/documentation necessary for contracts let with federal ESSER funds during our FY22 state audit. School Districts are usually not required to pay prevailing wages (state/local funds). The District had not used federal fu...

District Administration was originally made aware of the specific requirements/documentation necessary for contracts let with federal ESSER funds during our FY22 state audit. School Districts are usually not required to pay prevailing wages (state/local funds). The District had not used federal funds for construction in the past and was unaware of the requirement. On 9/27/22, the District policy (DJF), regarding purchasing procedures, was updated to include the Davis-Bacon requirements. The purchase orders for the $24,605 flooring project in question were created on 8/18/22 and checks were issued on 12/15/22, prior to our FY22 audit being completed and a corrective action plan being in place. The District intends to closely follow internal controls pertaining to federal grant management in order to prevent future issues as described in Finding 2023-001.

View Audit 12983

Finding 9470 (2023-001)

Material Weakness 2023

Regional School Unit#50

ME

Special Tests & Provisions

Regional School Unit 50 will take the following actions to address finding 2023-001: All Construction projects estimated at $2,000 or more will require a contract. All construction proposals and contracts in excess of $2,000 will be reviewed by the Business Manager to determine if the prevailing wag...

Regional School Unit 50 will take the following actions to address finding 2023-001: All Construction projects estimated at $2,000 or more will require a contract. All construction proposals and contracts in excess of $2,000 will be reviewed by the Business Manager to determine if the prevailing wage rate clause is needed. Each project will be reviewed along with the grant application to determine if there is a need to include a prevailing wage rate clause. No proposals of contracts being funded through federal assistance or with grants requiring the prevailing wage rate will be accepted by Regional School Unit 50 that do not include this clause. If determined that the Davis Bacon wage clause is required, the Business Manager will review to ensure that all language required by the Davis Bacon Wage Act is included.

View Audit 12979

Finding 9466 (2023-002)

None 2023

Warner University, Inc.

CO

Student Financial Aid Matching / Level of Effort / Earmarking

Late Return of Title IV (R2T4) Planned Corrective Action: With the understanding of the 49% exempt rule, all zero credits (Fs and/or Ws) will trigger an R2T4 process using the most recent withdrawal date or the last date of attendance. If there are any special circumstances, Warner will consult Ca...

Late Return of Title IV (R2T4) Planned Corrective Action: With the understanding of the 49% exempt rule, all zero credits (Fs and/or Ws) will trigger an R2T4 process using the most recent withdrawal date or the last date of attendance. If there are any special circumstances, Warner will consult CapinCrouse for their understanding and processing directions if there is no clear directive from the Department of Education regulations. All previous corrective actions for processing R2T4s still stand. In addition, all financial aid staff will participate in training to stay in compliance with any Title IV changes. Person Responsible for Corrective Action Plan: Elease C Cox, Director of Financial Aid and Compliance Anticipated Date of Completion: Already in effect, Summer 2023

View Audit 12966

Finding 9460 (2023-001)

Significant Deficiency 2023

Warner University, Inc.

CO

Subrecipient Monitoring Significant Deficiency

Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting th...

Gramm Leach Bliley Act Planned Corrective Action: The current Information Security Program was created using Capin's template last year and was acceptable. Moving forward, we will document the safeguards we're putting in place by including them in the Information Security Program and documenting the decreased mitigated risk level. We have a legacy on premise legacy SIS application software that doesn't have the capacity for MFA. We will attempt to either move our on-premise application software and database to our vendor's location where MFA is required to get into their network, or we will source a third-party vendor that will work with a legacy application without MFA capacity and require MFA on the front-end before calling the application. We will also consider application software on University-owned computer workstations and laptops that require MFA upon logging into our campus network. We will source an outside company for penetration testing and vulnerability scanning. Then, review the results and put in a plan to address the critical items and track progress. We will document each vendor that hosts PII data. We will collect SOC reports, privacy statements, GLBA compliance documents, and other related documents. We will provide the Board of Trustees - Business/Finance Committee a written report on the current status of the Information Security Program document. Person Responsible for Corrective Action Plan: Kelvin D Tohme, Senior Director of Information Technology Anticipated Date of Completion: Spring 2024

View Audit 12966

Finding 9456 (2023-001)

Material Weakness 2023

Cherry Creek School District No 5

CO

Allowable Costs / Cost Principles

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Special Education Cluster – Assistance Listing No. 84.017 and 84.173 Recommendation: We recommend the District review their controls and procedures surrounding time and effort certifications and reviewing individuals charged to...

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2023-001 Special Education Cluster – Assistance Listing No. 84.017 and 84.173 Recommendation: We recommend the District review their controls and procedures surrounding time and effort certifications and reviewing individuals charged to the grant to ensure allowability under 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 ensure time and effort certifications are performed as required and will ensure proper review of individuals charged to the grant to ensure allowability under the grant. Name of the contact person responsible for corrective action: Scott Smith, Chief of Operations and Finance Planned completion date for corrective action plan: January 1, 2024 If the Department of Education has questions regarding this plan, please call Scott Smith at 720-554-4344.

View Audit 12950

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Outside In will update our Procurement Policy to verify status of suspension or debarment for all potential contractors being considered for use of federal funds. The verification process will include one or more of the following verification methods to demonstrate compliance with federal regulation...

Outside In will update our Procurement Policy to verify status of suspension or debarment for all potential contractors being considered for use of federal funds. The verification process will include one or more of the following verification methods to demonstrate compliance with federal regulations before purchase of goods, contract for services (including purchase orders) or subaward funds.

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

1

View Audit 12942

Finding 9455 (2023-003)

Significant Deficiency 2023

Outside in

OR

Special Tests & Provisions Significant Deficiency

Obtain a signed certificate from the contractor attesting it is not suspended or debarred.

View Audit 12942

Corrective Action Plans

Filters