Corrective Action Plans

Finding 370282 (2022-001)

Material Weakness 2022

Fort Defiance Housing Corporation D/b/a Sandstone Housing

NM

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

2022-001: Submission of Single Audit Reports (Material Weakness) Federal Agency: U.S. Department of Agriculture (“USDA”) Program Title: Section 538 Rural Rental Housing Loans Assistance Listing Number: 10.438 Federal Award Source: Direct Funding Pass-Through Entity: N/A Pass-Through Identifying Numb...

2022-001: Submission of Single Audit Reports (Material Weakness) Federal Agency: U.S. Department of Agriculture (“USDA”) Program Title: Section 538 Rural Rental Housing Loans Assistance Listing Number: 10.438 Federal Award Source: Direct Funding Pass-Through Entity: N/A Pass-Through Identifying Number: N/A Criteria – Section 200.512 of the Uniform Guidance states that the single audit shall be completed and the data collection form and reporting package shall be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Condition and Context - The Organization did not complete its single audit and submit its data collection form and reporting package for the year ended December 31st, 2022 by the required deadline. Cause and Effect – Due to the delay in resolving the finding noted at 2022-02, the Organization was late in completing its single audit and submitting its data collection form and reporting package to the Federal Audit Clearinghouse. Questioned Costs - None identified. Recommendation – We recommend that the Organization improve its financial reporting close process in order to complete its annual single audit and submit the data collection form and reporting package to the Federal Audit Clearinghouse by the required deadline.

View Audit 291895

Finding 370280 (2022-010)

Significant Deficiency 2022

Birmingham-Southern College

AL

Internal Control / Segregation of Duties

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The offering of HEERF grant funding was emailed to all students. Students would opt in or opt out which would generate a response email. The acceptance responses were sent to two staff e-mails in the communication department a...

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The offering of HEERF grant funding was emailed to all students. Students would opt in or opt out which would generate a response email. The acceptance responses were sent to two staff e-mails in the communication department as well as the previous Financial Aid Director. Unfortunately, all three staff members have left BSC and their email accounts have been closed. Beginning the spring of 2022, all HEERF acceptance emails were saved in an institutional shared drive to ensure appropriate record keeping. Anticipated Completion Date: February 1, 2022

View Audit 291887

Finding 370279 (2022-009)

Significant Deficiency 2022

Birmingham-Southern College

AL

Internal Control / Segregation of Duties Reporting

Contact Person: Lane Estes, VP for Administration and Chief Operating Officer Corrective Action: The College experienced some staff changes in the financial aid and accounting offices. The College will update the required reporting on its website at https://www.bsc.edu/emergencyrelieffund.html. An...

Contact Person: Lane Estes, VP for Administration and Chief Operating Officer Corrective Action: The College experienced some staff changes in the financial aid and accounting offices. The College will update the required reporting on its website at https://www.bsc.edu/emergencyrelieffund.html. Anticipated Completion Date: December 18, 2023

View Audit 291887

Finding 370276 (2022-006)

None 2022

Birmingham-Southern College

AL

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

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the procedure to clearly specify a separate notice to all parents who borrow using the Parent Plus. Each borrowing parent will receive a notification ...

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the procedure to clearly specify a separate notice to all parents who borrow using the Parent Plus. Each borrowing parent will receive a notification mailed to the address used on the Parent Plus application. The current financial aid procedures were updated in spring of 2022 and carried out successfully. Anticipated Completion Date: June 1, 2023

View Audit 291887

Finding 370269 (2022-003)

None 2022

Birmingham-Southern College

AL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Contact Person: Dr. Laura Stultz, Interim Provost Corrective Action: The College has had significant staff turnover within the last year. The Office of Academic Records was operating with one staff member at that time. It is now operating at full staff capacity and will be better able to follow up ...

Contact Person: Dr. Laura Stultz, Interim Provost Corrective Action: The College has had significant staff turnover within the last year. The Office of Academic Records was operating with one staff member at that time. It is now operating at full staff capacity and will be better able to follow up on reporting errors to make necessary corrections. The findings for students with incorrect NSLDS status reports have already been corrected. Amy Smith has corrected those errors March 2023. The College is working on a better, more comprehensive withdrawal policy in the next academic year which will assist in identifying non-returning students at an earlier date to better fit the 60- day allotted time frame. In addition, the Office of Academic Records plans to alter enrollment reporting schedules to better fit our academic calendar to meet the 60-day time frame requirement. This change should capture our Fall and Winter graduates within the allotted time requirement. Anticipated Completion Date: March 2023

View Audit 291887

Finding 370268 (2022-002)

None 2022

Birmingham-Southern College

AL

Student Financial Aid Subrecipient Monitoring Cash Management

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the transmittal procedure to include reversing a federal aid posting in the event that it cannot be reconciled within ten days of its initial creation...

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the transmittal procedure to include reversing a federal aid posting in the event that it cannot be reconciled within ten days of its initial creation. The aid will be reposted once the issue is resolved and reported to COD on the day of positing. The current financial aid procedures have been updated. Anticipated Completion Date: June 1, 2023

View Audit 291887

Finding 370267 (2022-005)

None 2022

Birmingham-Southern College

AL

Special Tests & Provisions Procurement, Suspension & Debarment Student Financial Aid

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The loans have been purchased by Birmingham-Southern College. Anticipated Completion Date: January 10, 2024

View Audit 291887

Finding 370264 (2022-008)

Significant Deficiency 2022

Birmingham-Southern College

AL

Internal Control / Segregation of Duties Subrecipient Monitoring Special Tests & Provisions

Contact Person: Rusty Howell, AVP for Information Technology Corrective Action: The College will perform a risk assessment and document safeguards for identified risks. Anticipated Completion Date: November 8, 2023

View Audit 291887

Finding 370263 (2022-007)

Significant Deficiency 2022

Birmingham-Southern College

AL

Student Financial Aid Subrecipient Monitoring Reporting

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the rules in the SIS system to not allow payment until the NSLDS reporting has been processed. The current financial aid procedures have been updated ...

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Financial Aid Office has updated the rules in the SIS system to not allow payment until the NSLDS reporting has been processed. The current financial aid procedures have been updated and the rules are currently in place. Anticipated Completion Date: June 1, 2023

View Audit 291887

Finding 370262 (2022-004)

Significant Deficiency 2022

Birmingham-Southern College

AL

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

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Return to Title IV calculation was off due to the denominator of total days being incorrectly counted. The Director of Financial Aid will calculate the total days for each semester to...

Contact Person: Traci Veyl, Director of Financial Aid Corrective Action: The College agrees with this finding. The Return to Title IV calculation was off due to the denominator of total days being incorrectly counted. The Director of Financial Aid will calculate the total days for each semester to be used for the calculation and publish them in the annual policy and procedure manual. The current financial aid procedures have been updated. Anticipated Completion Date: June 1, 2023

View Audit 291887

Finding 370228 (2022-004)

Significant Deficiency 2022

School District of Wisconsin Dells

WI

Cash Management

Program Affected Medical Assistance Program Assistance Listing No. 93. 778 Criteria: For staff and contractors that provide direct medical services, Districts are required to report amounts paid for salaries, benefits, and contracted services through quarterly financial submissions. Condition: Th...

Program Affected Medical Assistance Program Assistance Listing No. 93. 778 Criteria: For staff and contractors that provide direct medical services, Districts are required to report amounts paid for salaries, benefits, and contracted services through quarterly financial submissions. Condition: The District did not report any salaries, benefits, or contracted services for the second quarter of 202 I. Cause: District staff did not properly report the expense information through the quarterly financial submission. Effect: Improperly reported expenses would affect the reimbursements received by the District under the SBS Medicaid program. Questioned Cost: None. Repeat Finding: No. Auditor's Recommendation: We recommend the District review its procedures for compiling and submitting the quarterly financial submissions to ensure that all salaries, benefits, and contracted costs are properly reported in the SBS Medicaid system. Grantee Response: This was related to the Staff Pool List not being submitted for the 4th quarter of FY21 (April-June 2021) on a timely basis. When the District contacted the SBS Medicaid claiming system, they said it was too late to enter the List. As a result, the District will review its procedures for submitting the Staff Pool Lists on time, and SBS training sessions will be utilized as needed. For this, the District will work in conjunction with our special education staff, who submit the Staff Pool List, to ensure the list is entered a week before the due date into the system. Once that is completed, in turn, all salaries, benefits and contracted costs will be able to be properly reported in the SBS Medicaid system and will be done so on a timely basis. Contact Person: District Administrator Terry Slack Anticipated Completion: June 30, 2023

View Audit 291819

Finding 370227 (2022-003)

Significant Deficiency 2022

School District of Wisconsin Dells

WI

Cash Management

Program Affected-Medical Assistance Program -Assistance Listing No. 93. 778 Criteria: Districts are required to report an IEP ratio and a one-way trip ratio on the Medicaid Annual Cost Report. The IEP ratio is the ratio of students with billed SBS Medicaid services to total students with a related...

Program Affected-Medical Assistance Program -Assistance Listing No. 93. 778 Criteria: Districts are required to report an IEP ratio and a one-way trip ratio on the Medicaid Annual Cost Report. The IEP ratio is the ratio of students with billed SBS Medicaid services to total students with a related medical service. The one-way trip ratio is the ratio of one-way trips for Medicaid-eligible students with specialized transportation needs in their IEP to total one-way trips by all students with specialized transportation needs in their IEP. Condition: The District did not maintain adequate documentation to support the ratios reported on the Medicaid Annual Cost Report. Cause: The values entered into the Medicaid Annual Cost report by District staff did not match the values calculated on the supporting documentation maintained by the District for each ratio. Effect: Improperly calculated ratios could affect reimbursements received from the SBS Medicaid program. Questioned Cost: Unknown Repeat Finding: Yes. Auditor's Recommendation: We recommend the District review its procedures for compiling the information used to calculate the IEP ratio and one-way trip ratio for the annual cost report. Training should be provided so staff can identify all students that should be included in the calcnlation and procedures should be implemented to review and verify that the calculation is con-eel. Grantee Response: The District will review its procedures for compiling the information used to calculate the ratios for the annual cost report, and training will be provided so staff can be sure to identify all students that should be included in the calculation are included. This will include the district's Director of Pupil Services review of this information on a monthly basis with the Business Manager to ensure procedures will be implemented to review and verify that the calculation is correct, which includes working with our SBS Medicaid provider, MJ Care, in conjunction with our special education director on these numbers. Contact Person: District Administrator Terry Slack Anticipated Completion: December 31, 2023

View Audit 291819

Finding 370222 (2022-002)

Significant Deficiency 2022

School District of Wisconsin Dells

WI

Cash Management School Nutrition Programs

Program Affected-Child Nutrition Cluster-Assistance Listing No. 10.555, 10.556, 10.559 Criteria: The Uniform Guidance requires the local program operator to submit monthly claims for reimbursement to the administering agency. All meals claimed for reimbursement must meet federal requirements and b...

Program Affected-Child Nutrition Cluster-Assistance Listing No. 10.555, 10.556, 10.559 Criteria: The Uniform Guidance requires the local program operator to submit monthly claims for reimbursement to the administering agency. All meals claimed for reimbursement must meet federal requirements and be served to eligible children. Condition: Audit sampling revealed variances between total meals claimed in monthly food service claims and the meal cotmt sheets that the District used to track meals served to students. Cause: Meal counts were not accurately reported on the claim forms in the months sampled. Effect: Excess reimbursement amounts claimed may be disallowed and, if any, the excess may need to be returned to the federal agency. Questioned Cost: Unknown. Repeat Finding: Yes. Auditor's Recommendation: We recommend the District set up a review procedure to review the claims and reconcile the claims to actual meals served. Grantee Response: The District has reviewed procedures and implemented a system to review the claims and reconcile the claims to actual meals served. This will be done by entering the actual meals served in our computer system (Skyward) on an ongoing basis at the point of service, meaning the meals are entered daily into the system as students/staff go through the food service line at their school. This is a change from the past--<luring COVID, when all meals were served free to all students. At that time, our previous food service director used a manual, "tally" method, as a result of being short staffed. Now, we have a new food service director and we are going to keep all of our meal counts up to date in Skyward, as opposed to using the manual, "tally" method from the past two years. Contact Person: District Administrator Terry Slack Anticipated Completion: December 31, 2023

View Audit 291819

Finding 370209 (2022-001)

Significant Deficiency 2022

Envision Community Services INC

IL

Reporting Internal Control / Segregation of Duties

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of direc...

We will have our current accountant set a schedule for performing monthly closes of the financial statements so they can be presented in summary format to management and the board of directors. We will require that the President/CEO and other key members of the management team and the board of directors review the monthly financial reports provided by the accountant so that all board members understand the financial position and results of activities of ECS on a regular and consistent basis. Finally, we will develop a transition plan with procedures requiring that whomever is responsible for the accounting and financial reporting function for ECS reconcile all financial accounts and close the financial records for the month prior to departure to ensure a smooth transition ECS’s accounting and financial reporting function to the next person responsible for its maintenance

View Audit 291791

Finding 370208 (2022-008)

Significant Deficiency 2022

Africatown Community Land Trust

WA

Reporting Significant Deficiency § 200.512

Finding 2022-008: Deadline for Federal Single Audit – Significant Deficiency. Response: 1. Audits will be performed on time beginning in 2024. 2. We will ensure that the Data Collection Form is completed online at h

View Audit 291780

Finding 370207 (2022-007)

Significant Deficiency 2022

Africatown Community Land Trust

WA

Subrecipient Monitoring Reporting Significant Deficiency § 200.328

Finding 2022-007: Reporting – Significant Deficiency. Response: 1. Staff are being trained to understand the significance of meeting deadlines. 2. New system that includes grant reporting requirements will be implemented in 2024. 3. Reporting tasks are being redistributed to assure tasks are comple...

Finding 2022-007: Reporting – Significant Deficiency. Response: 1. Staff are being trained to understand the significance of meeting deadlines. 2. New system that includes grant reporting requirements will be implemented in 2024. 3. Reporting tasks are being redistributed to assure tasks are completed by their due dates.

View Audit 291780

Finding 370206 (2022-006)

Material Weakness 2022

Africatown Community Land Trust

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.317 § 200.318 § 200.327

Finding 2022-006: Procurement, Suspension, and Debarment – Material Weakness. The buying policy ordering process has been updated to include blocking GSA (Government Services Administration) & HHS (Health & Human Services) disbarred sellers in accordance with SAM (System of Award Management) system...

Finding 2022-006: Procurement, Suspension, and Debarment – Material Weakness. The buying policy ordering process has been updated to include blocking GSA (Government Services Administration) & HHS (Health & Human Services) disbarred sellers in accordance with SAM (System of Award Management) system. The overall Procurement policy, contracts and forms will be updated to include suspension and debarment language.

View Audit 291780

Finding 370205 (2022-005)

Material Weakness 2022

Africatown Community Land Trust

WA

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.400

Finding 2022-005: Activities Allowed, Allowable Costs, and Period of Performance – Material Weakness. Management Response: We are reviewing our internal controls (SOPs, Operational Manuals and Handbooks), including the document retention policy to assure retrieval. Interdepartmental review of the p...

Finding 2022-005: Activities Allowed, Allowable Costs, and Period of Performance – Material Weakness. Management Response: We are reviewing our internal controls (SOPs, Operational Manuals and Handbooks), including the document retention policy to assure retrieval. Interdepartmental review of the program contract and the Operations Manual will be held to assure understanding of allowable expenses. 1. Managerial training will be administered to assure Program expenditures are allowable. 2. Operations Manual is being updated to have a process that insures approval workflows for allowable costs. 3. Accounting Policies & Procedures Manual is being updated to improve internal controls & show clear process of compliance over expenditures.

View Audit 291780 Questioned Costs: $1

Finding 370204 (2022-004)

Material Weakness 2022

Africatown Community Land Trust

WA

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

Finding 2022-004: Internal controls over compliance Material Weakness Management Response: This was the first year that we received more than $750,000 and are working to implement controls, policies & practices that are in compliance with the federal awards requirements & guidelines. A recent site ...

Finding 2022-004: Internal controls over compliance Material Weakness Management Response: This was the first year that we received more than $750,000 and are working to implement controls, policies & practices that are in compliance with the federal awards requirements & guidelines. A recent site visit by KCRHA resulted in our updating documents to comply with City, County & Federal requirements.

View Audit 291780

Finding 370193 (2022-002)

Significant Deficiency 2022

Ohio Tri-County Food Alliance Dba Second Harvest Foodbank

OH

Finding 2022-002 - USDA Food Distribution- The Organization encountered challenges in obtaining "approved shopper" signatures on food invoices for partner agencies due to turnover in the Inventory staff. However, the staffing issue has been addressed, and the new staff members have received adequate...

Finding 2022-002 - USDA Food Distribution- The Organization encountered challenges in obtaining "approved shopper" signatures on food invoices for partner agencies due to turnover in the Inventory staff. However, the staffing issue has been addressed, and the new staff members have received adequate training. Austin Wilson, in their capacity as Network Membership Specialist, will oversee the training of staff in Inventory procedures to ensure smooth operations moving forward.

View Audit 291752

Finding 370192 (2022-001)

Significant Deficiency 2022

Ohio Tri-County Food Alliance Dba Second Harvest Foodbank

OH

Reporting § 200.512

Finding 2022-001- Federal Audit Clearinghouse (FAC)- 20 N. Murray Street Springfield, Ohio 45503 93 7.325.8715 thes hfb.org The Organization recognizes its lapse in filing the F AC on time. Amidst changes in accounting personnel and the Executive Director role throughout 2022 and early 2023, the Org...

Finding 2022-001- Federal Audit Clearinghouse (FAC)- 20 N. Murray Street Springfield, Ohio 45503 93 7.325.8715 thes hfb.org The Organization recognizes its lapse in filing the F AC on time. Amidst changes in accounting personnel and the Executive Director role throughout 2022 and early 2023, the Organization has now appointed a Finance Director and filled the Executive Director position. Faith Schiffer, the new Finance Director, will oversee the timely completion of the financial statement audit and ensure the F AC filing meets its deadline.

View Audit 291752

Finding 370173 (2022-222)

Significant Deficiency 2022

Cheder Toras Zev

NJ

Subrecipient Monitoring

Finding 22-2: The school’s net cash resources exceeded three months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the is...

Finding 22-2: The school’s net cash resources exceeded three months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of February 6, 2024. Person Responsible for Implementation: Chaim Eidelman, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: (732)901-5060.

View Audit 291704

Finding 370172 (2022-221)

Significant Deficiency 2022

Cheder Toras Zev

NJ

Finding 22-1: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: To maintain all documentation that will be required for the audit in an organized manner in order to enable the auditor to com...

Finding 22-1: The audit report was due to be received by the State of New Jersey no later than May 31, 2023. As a result, the audit was not submitted timely. Recommendation: To maintain all documentation that will be required for the audit in an organized manner in order to enable the auditor to complete the audit in a timely manner. Action Taken: Since being made aware of the issue, the administrator and his staff updated their system for storing audit documentation which will help the auditor receive all the necessary information in enough time to complete the audit in a timely manner. Implementation Date: Corrective Action Plan has been implemented as of February 6, 2024. Person Responsible for Implementation: Chaim Eidelman, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: (732)901-5060.

View Audit 291704

Finding 370151 (2022-007)

Significant Deficiency 2022

Town of Livermore Falls

ME

Cash Management § 200.302 § 200.305

The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Pol...

The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. This policy was approved and implemented by the Select Board on January 23, 2024.

View Audit 291679

Finding 370150 (2022-006)

Material Weakness 2022

Town of Livermore Falls

ME

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

The Town Manager and Select Board will take the following actions to address finding 2022-006: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy t...

The Town Manager and Select Board will take the following actions to address finding 2022-006: The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy that will address this deficiency. The Select Board will review this draft at their meeting in February or March 2024, edits will be made and then it will be sent to legal for final review before adoption. This policy will include sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll.

View Audit 291679

Corrective Action Plans

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