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Corrective Action Plans

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Finding 992 (2023-001)
Significant Deficiency 2023
Realife Cooperative of Eau Claire
WI
Internal Control / Segregation of Duties
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempt...
Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.
View Audit 1887
Kenwood Place Ii, Inc.
IN
HUD Housing Programs Reporting
Findings - Financial Statement Audit: None Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2023-001: Section 202 Capital Advance, CFDA 14.157 Recommendation: Make the required delinquent deposit to the replacement reserve account and ensure that a...
Findings - Financial Statement Audit: None Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2023-001: Section 202 Capital Advance, CFDA 14.157 Recommendation: Make the required delinquent deposit to the replacement reserve account and ensure that all future deposits are made as required by the Regulatory Agreement. Action Taken: Management will make the required replacement reserve deposits as soon as possible and will ensure compliance in the future.
View Audit 1884
Kenwood Place I, Inc.
IN
HUD Housing Programs Reporting Internal Control / Segregation of Duties
Findings - Financial Statement Audit: None Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2023-001: Section 223(f) Loan Program, CFDA 14.155 Recommendation: Make the required delinquent deposit to the replacement reserve account and ensure that a...
Findings - Financial Statement Audit: None Findings - Federal Award Programs Audit: U.S. Department of Housing and Urban Development Finding 2023-001: Section 223(f) Loan Program, CFDA 14.155 Recommendation: Make the required delinquent deposit to the replacement reserve account and ensure that all future deposits are made as required by the Regulatory Agreement. Action Taken: Management will make the required replacement reserve deposits as soon as possible and will ensure compliance in the future.
View Audit 1882
Finding 986 (2023-001)
Material Weakness 2023
Northwest Health Services, Inc.
MO
Procurement, Suspension & Debarment
We concur with this finding. Management recognizes the importance of complying with NHS’ federal procurement policy. Procurement policy and procedure was thoroughly reviewed and revised accordingly when compared to the federal procurement policy. The procurement policy was approved by Board of Direc...
We concur with this finding. Management recognizes the importance of complying with NHS’ federal procurement policy. Procurement policy and procedure was thoroughly reviewed and revised accordingly when compared to the federal procurement policy. The procurement policy was approved by Board of Directors on November 29, 2022. When finding 2022-003 was presented to us by the auditors in August 2022, the procurements referred to in finding 2023-001 had already taken place. Going forward, the procurement policy will be reviewed on a regular basis to ensure that personnel involved in procurement are educated with regards to the procurement policy and procedures. Additionally, the procurement policy will be reviewed on an annual basis to ensure it is consistent with the Uniform Guidance. Contact Person: Tina Harris, CFO Completion Date: November 29, 2022
View Audit 1866
Finding 985 (2023-002)
Significant Deficiency 2023
Lawrence Public Schools
MI
Internal Control / Segregation of Duties Significant Deficiency Special Tests & Provisions
All capital and repair project requests for proposals shall explicitly express language regarding Davis-Beacon / Prevailing Wage. The process for awarding bids (rubric) and contracts will be adjusted to include a section which references prevailing wage. Superintendent will continue working with t...
All capital and repair project requests for proposals shall explicitly express language regarding Davis-Beacon / Prevailing Wage. The process for awarding bids (rubric) and contracts will be adjusted to include a section which references prevailing wage. Superintendent will continue working with the current vendor to gain assurances that prevailing wages were offered for labor on the FY 2023 project.
View Audit 1863
Finding 979 (2023-002)
Material Weakness 2023
Grafton Public School District No. 18
ND
Special Tests & Provisions § 200.326
Contact Person Darren Albrecht Planned Corrective Action Activities Director Jon Koehmstedt 1548 School Road 701-352-1930 701-352-1943 Fax The District will plan to get payroll registers monthly from contractors moving forward. Planned Completion Date The planned completion date is June 30, 2024.
Contact Person Darren Albrecht Planned Corrective Action Activities Director Jon Koehmstedt 1548 School Road 701-352-1930 701-352-1943 Fax The District will plan to get payroll registers monthly from contractors moving forward. Planned Completion Date The planned completion date is June 30, 2024.
View Audit 1857
Finding 972 (2023-001)
Significant Deficiency 2023
Prairiestar Health Center, Inc.
KS
Special Tests & Provisions Eligibility
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and ...
During the 2023 audit of PrairieStar Health Center, FORVIS found two issues with the sliding fee set up. The first issue was that CPT code 73610 was attached to the wrong slide level due to a change in price. The CPT code was attached to the Radiology 2 group which is for CPTs between $100.00 and $114.99. The price of the CPT had been changed from $102.00 to $120.00 and should have been moved to the Radiology 3 group which is for CPTs between $115.00 and $169.99. The second issue was that CPT code 90620 was not set up to slide. In the six and one-half years that I have been at PrairieStar, we have made great strides in identifying CPT codes that were not attached to a sliding fee group and correcting them. I feel that this is a rare CPT code that has been missed in our review. Plan to Correct Finding Multiple steps have or will be taken to correct this finding. • Both of the errors above have been corrected in our EMR. • We are getting ready to update pricing. As part of this update, I will review the slide group attached to each CPT code to make sure that the correct slide is attached. • We will continue to randomly review sliding fee calculations each month to help identify any errors in sliding fee calculations or setup. Date of Completion Both of the errors described above have been corrected. There is no completion date for the monthly review. This is a part of our monthly routine. Responsible Party Shandi Stallman, Chief Financial Officer, is the party that has overall responsibility for this corrective action.
View Audit 1839
Finding 969 (2023-001)
Material Weakness 2023
Melvindale-Northern Allen Park Public Schools
MI
Cash Management
2023-001 Material Noncompliance: material weakness in internal controls over compliance • Cash drawdowns for the ESSER program exceeded expenditures for one transaction/event o The Director of Finance will review the ledger and amounts requested for grant drawdowns with another member of the bus...
2023-001 Material Noncompliance: material weakness in internal controls over compliance • Cash drawdowns for the ESSER program exceeded expenditures for one transaction/event o The Director of Finance will review the ledger and amounts requested for grant drawdowns with another member of the business department before submitting the request. Both members of the business department will sign the ledger to document that the numbers were correct.
View Audit 1816
Finding 967 (2023-001)
Material Weakness 2023
St. Charles Community Schools
MI
Corrective Action Plan Reference number assigned: 2023-001 Material Weakness and Material Noncompliance - Budget Variances Condition: A material budget overage was noted in the General Fund for basic programs. A material overage was noted in the Education Stabilization Fund for instructional staf...
Corrective Action Plan Reference number assigned: 2023-001 Material Weakness and Material Noncompliance - Budget Variances Condition: A material budget overage was noted in the General Fund for basic programs. A material overage was noted in the Education Stabilization Fund for instructional staff salaries and benefits. There also was a material budget overage in the Education Stabilization Fund in capital outlay when compared to the MEGS budget. Action Plan: St. Charles Community School's Finance Director and Superintendent will monitor the budget throughout the school year for all funds, and will follow the established policies regarding budget preparation and implementation. St. Charles Community School's Finance Director and Superintendent will stay current with changes in available funding, and will analyze expenses when amending the final budget and MEGS budget to ensure the district is in compliance. Anticipated completion date: June 30, 2024 Material Weakness and Material Noncompliance - Budget Variances/Allowable Costs Condition: Budget overages were noted in the General Fund. A material overage was noted in the general Fund for both the ESSER Ill MEGS budget and final budget approved by the board. Action Plan: St. Charles Community School's Finance Director and Superintendent will monitor the budget throughout the school year for all funds, and will follow the established policies regarding budget preparation and implementation. Budget amendments will be conducted throughout the school year to avoid overages. Anticipated completion date: June 30, 2024
View Audit 1803
Finding 966 (2023-003)
Significant Deficiency 2023
Mt. Auburn Housing, Inc.
OH
Questioned Costs Internal Control / Segregation of Duties
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that four reserve for replacement deposits were missed during the year. S3800-130 Response Indicator Agree S3800-140 Completion Date 5/18/2023 S3800-150 Response The Corporation transferr...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that four reserve for replacement deposits were missed during the year. S3800-130 Response Indicator Agree S3800-140 Completion Date 5/18/2023 S3800-150 Response The Corporation transferred the funds into the Reserve for Replacement account on May 18, 2023 S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
View Audit 1800 Questioned Costs: $1
Finding 965 (2023-002)
Significant Deficiency 2023
Mt. Auburn Housing, Inc.
OH
Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2023 S3800-150 Response The Corporation is working with HUD and ...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2023 S3800-150 Response The Corporation is working with HUD and a local developer to resolve the outstanding loan balance. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
View Audit 1800 Questioned Costs: $1
Finding 964 (2023-001)
Significant Deficiency 2023
Mt. Auburn Housing, Inc.
OH
Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2023 S3800-150 Response The Corporation is working with HUD and ...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2023 S3800-150 Response The Corporation is working with HUD and a local developer to resolve the outstanding loan balance. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar
View Audit 1800 Questioned Costs: $1
Finding 959 (2023-004)
Material Weakness 2023
Bullock Creek School District
MI
Internal Control / Segregation of Duties Cash Management Material Weakness
October 24, 2023 Finding Number: 2023-004 – Material weakness in Internal Control – Reporting (Repeat Finding) Condition: In six of the eleven months tested, the number of meals included on the reimbursement claim reports were not supported by the District’s internal count sheets. Responsible Pe...
October 24, 2023 Finding Number: 2023-004 – Material weakness in Internal Control – Reporting (Repeat Finding) Condition: In six of the eleven months tested, the number of meals included on the reimbursement claim reports were not supported by the District’s internal count sheets. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 This year we have partnered with Meal Magic, for reporting claims. Every student must enter an identification number or scan an ID card so that students cannot be missed or over-claimed. The Direct Certification students are compared monthly against the state information provided to make sure students are claimed at the correct rate. Sincerely, Stephen Grubaugh Director of Business Service
View Audit 1794
Finding 954 (2023-003)
Significant Deficiency 2023
Bullock Creek School District
MI
School Nutrition Programs Cash Management Eligibility
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Imple...
October 24, 2023 Finding Number: 2023-003 – Significant Deficiency in Internal Control – Eligibility Condition: Of the 22 applications for reduced meals that were selected for testing, 3 did not document evidence of review by staff. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 This year we have a 2-person checking system, Kim Gagne initially completes the applications with a signature and Jody King double checks every application for errors and oversites and adds her signature also. Both have been through the MDE training on the applications and the required information they need. Sincerely, Stephen Grubaugh Director of Business Services
View Audit 1794
Finding 949 (2023-002)
Significant Deficiency 2023
Bullock Creek School District
MI
School Nutrition Programs Significant Deficiency Internal Control / Segregation of Duties
October 24, 2023 Finding Number: 2023-002 – Significant Deficiency in Internal Control / Noncompliance – On-Site Reviews Condition: An on-site review was not completed for all sites in which lunches were served. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-2...
October 24, 2023 Finding Number: 2023-002 – Significant Deficiency in Internal Control / Noncompliance – On-Site Reviews Condition: An on-site review was not completed for all sites in which lunches were served. Responsible Person: Kim Gagne – Director of Food Service Implementation Date: 10-24-2023 On-site reviews for Lunch and Breakfast are mapped out on the calendar to have completed by Kim Gagne before the due date of Feb 1st, for all 5 schools. This time line will give the time to make sure deficiencies are addressed and corrected. Sincerely, Stephen Grubaugh Director of Business Services
View Audit 1794
Senior Residence at Kapolei 2, Inc.
HI
HUD Housing Programs Cash Management
1. Ref. No. 2023-001: Payment and Deposit of Residual Receipts Recommendation: The Company should ensure that it makes the full required residual receipt deposit before calculating the payments for other purposes. The Company should also transfer the remaining balance of $12,042 to the residual r...
1. Ref. No. 2023-001: Payment and Deposit of Residual Receipts Recommendation: The Company should ensure that it makes the full required residual receipt deposit before calculating the payments for other purposes. The Company should also transfer the remaining balance of $12,042 to the residual receipts account for fiscal year 2022. Action Taken: The Company deposited $12,042 into the residual receipts account on August 29, 2023. Contact person: Patrick Delaney (808) 523-5681, ext. 693 Anticipated Completion Date: Complete
View Audit 1790
Pacific Housing Oahu Corporation Kapolei Residence
HI
HUD Housing Programs Cash Management
1. Ref. No. 2023-001: Payment and Deposit of Residual Receipts Recommendation: The Company should ensure that it makes the full required residual receipt deposit before calculating the payments for other purposes. The Company should also transfer the remaining balance of $7,050 to the residual re...
1. Ref. No. 2023-001: Payment and Deposit of Residual Receipts Recommendation: The Company should ensure that it makes the full required residual receipt deposit before calculating the payments for other purposes. The Company should also transfer the remaining balance of $7,050 to the residual receipts account for fiscal year 2022. Action Taken: The Company has deposited $7,050 into the residual receipts account. Contact person: Patrick Delaney (808) 523-5681, ext. 693 Anticipated Completion Date: Completed
View Audit 1789
Finding 925 (2023-002)
Significant Deficiency 2023
Kenowa Hills Public Schools
MI
Questioned Costs Subrecipient Monitoring School Nutrition Programs
Kenowa Hills Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2023 District Contact Person: John Gilchrist, Director of Fina...
Kenowa Hills Public Schools respectfully submits the following corrective action plan for the year ended June 30, 2023. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended June 30, 2023 District Contact Person: John Gilchrist, Director of Finance The findings from the June 30, 2023 schedule of findings and responses are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding - Financial Statement Audit Finding 2023-001 Considered a material weakness Recommendation: The District should ensure that reconciliations are completed in a timely manner in order to correct any potential errors sooner. Action to be Taken: Management agrees with the finding and we are in the process of developing a plan as recommended. Finding – Federal Award Findings and Question Costs Finding 2023-002 Considered a significant deficiency Recommendation: The District should thoroughly train staff on their responsibilities for how to properly count meals served to ensure accurate record keeping. Action to be Taken: Management agrees with the finding and has implemented procedures to thoroughly train staff on how to accurately count meals and maintain records.
View Audit 1755 Questioned Costs: $1
Finding 923 (2023-001)
Significant Deficiency 2023
The Broadway House Corporation
AZ
Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties
We concur that the required increase in the monthly deposits to the reserve for replacement was not implemented on a timely basis. We have re-trained the management staff to follow up with the HUD and contractor administrator staff to forward the increase to the reserve for replacement deposit as pa...
We concur that the required increase in the monthly deposits to the reserve for replacement was not implemented on a timely basis. We have re-trained the management staff to follow up with the HUD and contractor administrator staff to forward the increase to the reserve for replacement deposit as part of the OCAF rent increase for properties we manage. We contated the mortgage company and the additional $1,148 shortfall was wired from the property bank account on August 17, 2023. This was resolved as fo August 31, 2023.
View Audit 1745 Questioned Costs: $1
The Master's University & Seminary and Subsidiary
CA
Subrecipient Monitoring
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 16 CFR 314.4(b)(1) - Written Documentation of Risk Assessment TMUS has established a risk assessment but has not recently completed due diligence due to staffing fluctuations which are currently being addressed. We will re-est...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: 16 CFR 314.4(b)(1) - Written Documentation of Risk Assessment TMUS has established a risk assessment but has not recently completed due diligence due to staffing fluctuations which are currently being addressed. We will re-establish the routine of analyzing and updating the risk assessment to rightly inform our security efforts and ensure appropriate personnel resources are dedicated to this effort. 16 CFR 314.4(c)(1-8) - Multi-factor Authentication The majority of the applications utilized by TMUS are leveraging MFA. We will direct resources to evaluate the minority of systems that do not currently utilize MFA and seek to migrate to an MFA enabled solution this year. In addition, we will complete an internal evaluation of our existing usage of MFA to ensure it is appropriately utilized and triggered per the recommendations noted. 16 CFR 314.4(i) - Annual Board Report TMUS utilizes a security and risk committee as part of our governing board. We plan to expand the scope of our committee meetings to review the status of the information security program and current levels of compliance. In addition, we will take steps to provide appropriate materials to the entire governing board to keep them informed regarding the effectiveness of the program. Person Responsible for Corrective Action Plan: Paul Sedy, Chief Information Officer Anticipated Date of Completion: By 6/30/2024
View Audit 1702
Finding 915 (2023-001)
Significant Deficiency 2023
Breckenridge Community Schools
MI
Allowable Costs / Cost Principles § 200.402
The Business Manager will review all grant agreements to gain a thorough understanding of allowable costs and then establish and modify or amend grant budgets appropriately to assure that only allowable costs are charged to federal grants. The Superintendent will review all federal budget amendment...
The Business Manager will review all grant agreements to gain a thorough understanding of allowable costs and then establish and modify or amend grant budgets appropriately to assure that only allowable costs are charged to federal grants. The Superintendent will review all federal budget amendments. We will put this into effect immediately going forward in all future grant agreements.
View Audit 1694
John Brown University and Affiliates
AR
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action:  The Registrar’s Office employee account used for access to the National Student Clearinghouse (NSC) website has been configured for multi-factor authentication (MFA).  The board report documentation has been modified to include ...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action:  The Registrar’s Office employee account used for access to the National Student Clearinghouse (NSC) website has been configured for multi-factor authentication (MFA).  The board report documentation has been modified to include the required sections and will be presented as a written supplement at the fall meeting, October 6, 2023. Person Responsible for Corrective Action Plan: Paul Nast, CIO Anticipated Date of Completion: Implemented September 26, 2023
View Audit 1692
Finding 907 (2023-001)
Significant Deficiency 2023
John Brown University and Affiliates
AR
Student Financial Aid Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: A new administrative withdrawal procedure has been created to ensure that Title IV is both timely and accurately returned to the Federal Government in the case of an official / unofficial withdrawal from the universit...
Inaccurate and Untimely Return of Title IV Funds (R2T4) Planned Corrective Action: A new administrative withdrawal procedure has been created to ensure that Title IV is both timely and accurately returned to the Federal Government in the case of an official / unofficial withdrawal from the university. A shared Office365 document was created to track the number of days in each segment of the withdrawal process. The Student Financial Services (SFS) Representative initiates the process upon notification of withdrawal from the Registrar. Appropriate documentation is gathered at the time of withdrawal to establish the correct timeline for the potential return of Title IV funds. The SFS Representative then determines if an R2T4 calculation is required. If an R2T4 calculation is required, the SFS Representative will assign the task to the Student Loan Processor or the Director of Student Financial Services. The Student Loan Processor and Director of Student Financial Services will use Microsoft Outlook, as prompted by the shared Office365 document, to assign “due dates” for both the R2T4 calculation as well as the return of funds to COD to ensure compliance. The Director of Student Financial Services and the Chief Student Finance Officer will perform a weekly review of the shared Office365 document to confirm the accuracy of R2T4 calculations and the required timeline of the return of Title IV funds. A secondary review by a financial aid representative with the appropriate level of experience will ensure that internal controls over such processes can operate effectively and achieve compliance. Person Responsible for Corrective Action Plan: David Burney, Chief Student Finance Officer Anticipated Date of Completion: Implemented August 21, 2023
View Audit 1692
Finding 906 (2023-003)
Significant Deficiency 2023
Litchfield Community Unit School District No. 12
IL
Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles
2023-003 Condition: The District submitted an expenditure to the Illinois State Board of Education in excess of the budget. Recommendation: The District should ensure that the expenditure reports filed with the Illinois State Board of Education are in accordance with the items included in the bu...
2023-003 Condition: The District submitted an expenditure to the Illinois State Board of Education in excess of the budget. Recommendation: The District should ensure that the expenditure reports filed with the Illinois State Board of Education are in accordance with the items included in the budget. Management Response: The District will take the necessary steps to ensure the expenditures fall within the budget line items. If necessary, the District will amend the budget to avoid over expending a line item in the original budget. Anticipated Date of Completion: June 30, 2024
View Audit 1684 Questioned Costs: $1
Finding 905 (2023-002)
Significant Deficiency 2023
Litchfield Community Unit School District No. 12
IL
Reporting Internal Control / Segregation of Duties
2023-002 Condition: The District’s general ledger expense account functions and objects do not agree to the account functions and objects that were reported to the Illinois State Board of Education on the quarterly expenditure reports and budgets approved by the Illinois State Board of Education. ...
2023-002 Condition: The District’s general ledger expense account functions and objects do not agree to the account functions and objects that were reported to the Illinois State Board of Education on the quarterly expenditure reports and budgets approved by the Illinois State Board of Education. Recommendation: The District should ensure that the expenditure reports filed with the Illinois State Board of Education are reconciled with the general ledger accounts of the District prior to submission. Management Response: The District will take the necessary steps to reconcile the expenditure reports with the general ledger accounts before submitting to the Illinois State Board of Education. Anticipated Date of Completion: June 30, 2024
View Audit 1684
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