Corrective Action Plans

Finding 75488 (2022-002)

Significant Deficiency 2022

OR

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.430

Recommendation: We recommend that the University increase the time and effort certification process to be more timely Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: Sponsored Projects Administration (SPA) will decrease ...

Recommendation: We recommend that the University increase the time and effort certification process to be more timely Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action in Response to Finding: Sponsored Projects Administration (SPA) will decrease the amount of the time between the end of the semi-annual reporting periods and distribution of the Personnel Activity Reports (PARs). Deadlines for either certifying that the charges to sponsored awards reported on the PARs reasonably reflects the work activities for those projects or notifying SPA that salary adjustments are required. SPA will send reminder notices periodically prior to the deadline. After the deadline for the reporting period, past due notices will be sent repeatedly after the deadline until certification or notification of adjustments is received. SPA will establish a system for accepting change notifications and closely monitor the status of retroactive labor adjustments so that updated PARs can be issued, reviewed, and certified in a timely manner. Name of the contact person responsible for corrective action: Dawn Boatman, Assistant Vice President for Research Administration Planned completion date for corrective action plan: July 1, 2023

View Audit 68909

Finding 75487 (2022-001)

Significant Deficiency 2022

Beechview Manor, Inc.

PA

HUD Housing Programs Procurement, Suspension & Debarment Eligibility

Beechview Manor CORRECTIVE ACTION PLAN March 24, 2023 United States Department of Housing and Urban Development Beechview Manor, Inc., respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Maher Du...

Beechview Manor CORRECTIVE ACTION PLAN March 24, 2023 United States Department of Housing and Urban Development Beechview Manor, Inc., respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Maher Duessel, CPA's 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2022 - December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT See Below FINDINGS? FEDERAL AWARD PROGRAMS AUDITS Finding 2022-001 Department of Housing and Urban Development Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects - Section 223(f)/207 ALN 14.155. Recommendation: The Property should have internal controls in place to review Form HUD-50059 to ensure all documentation used to calculate the tenant rent and assistance payment is supported and properly calculated. Action taken: The Property Manager has a Recertification Checklist. The managers have been reminded to utilize the checklist to its fullest at tenant recertification. Also, managers have been reminded to double check all calculations after submitting rent calculations to the servicer, Paulhus and Associates. If the Department of Housing and Urban Development has questions regarding this plan, please call Dan Barbusio at 412-646-5193.

View Audit 66138

Finding 75476 (2022-001)

Significant Deficiency 2022

Lehigh Valley Health Network and Subsidiaries

PA

Reporting § 200.303 § 200.502 § 200.510

Corrective Action Plan Finding No. 2022-001: HRSA COVID-19 Claims Reimbursement for the Uninsured Program Corrective Action Plan Since the inception of the program, the Organization reported the HRSA COVID-19 for the Uninsured based on payment date rather than on date of service/ incurred date. ...

Corrective Action Plan Finding No. 2022-001: HRSA COVID-19 Claims Reimbursement for the Uninsured Program Corrective Action Plan Since the inception of the program, the Organization reported the HRSA COVID-19 for the Uninsured based on payment date rather than on date of service/ incurred date. Once the error was identified, management properly reported and corrected the SEFA for the year ended June 30, 2022 to reflect the total amount of claims for services provided during the year ended June 30, 2022 for the Uninsured Program. Corrective Actions Taken Management has implemented the above corrective action. The VP of Patient Financial Services is providing the HRSA COVID-19 for the Uninsured based on date of service/incurred date, therefore the SEFA is properly reported for the year ended June 30, 2022. Completion Date: June 30, 2022 Contact Persons: Deborah Gaugler, Controller Jeffrey Hinkle, VP Patient Financial Services

View Audit 66134

Finding 75385 (2022-002)

Significant Deficiency 2022

Carroll County

IL

Procurement, Suspension & Debarment § 200.320

Finding 2022-002 ? Procurement in Compliance with Uniform Guidance Corrective Action Plan The County will adopt a procurement policy in compliance with the requirements of the Uniform Guidance. Person(s) Responsible: Mike Doty, County Administrator Timing for Implementation: November 30, 2022

View Audit 66838

Finding 75384 (2022-003)

Significant Deficiency 2022

Agape Child and Family Services, Inc.

TN

Eligibility

Effective immediately, supervisors will review and confirm program eligibility at in-take and document that review on the participants profile to create an audit trail.

View Audit 64388

Finding 72920 (2022-002)

Material Weakness 2022

Lisbon Community School Distirct

IA

We have reviewed procedures and plan to make the necessary changes to improve internal control.

View Audit 66132

Finding 72447 (2022-001)

Significant Deficiency 2022

Housing 1989

IL

HUD Housing Programs

Corrective Action Plan We will make timely deposits into the Replacement Reserve account. Anticipated Completion Date No later than the end of each month. Responsible Parties Tammy Grissom, Accounts Payable Angie Dean, Director of Finance

View Audit 63283

Finding 72376 (2022-003)

Material Weakness 2022

Sierra Nevada College

NV

Material Weakness Reporting Significant Deficiency

Finding 2022-003 U.S. Department of Education Higher Education Emergency Relief Fund COVID ? 19 Higher Education Emergency Relief Fund ? Student Portion, Assistance Listing 84.425E P425E200015 Reporting Material Weakness in Internal Control over Compliance Finding Summary: In the current year ...

Finding 2022-003 U.S. Department of Education Higher Education Emergency Relief Fund COVID ? 19 Higher Education Emergency Relief Fund ? Student Portion, Assistance Listing 84.425E P425E200015 Reporting Material Weakness in Internal Control over Compliance Finding Summary: In the current year the quarterly HEERF reports were reported on a cumulative basis rather than only reporting the information for that quarter as per the guidance from the Department of Education. Responsible Individuals: Maia Rowland, Student Financial Aid Director Corrective Action Plan: This issue will cease to exist in the future due to the acquisition of SNU by UNR. The acquisition of SNU by UNR was effective July 1, 2022. Anticipated Completion Date: This issue will cease to exist in the future due to the acquisition of SNU by UNR. The acquisition of SNU by UNR was effective July 1, 2022.

View Audit 64382

Finding 72371 (2022-002)

Material Weakness 2022

Sierra Nevada College

NV

Student Financial Aid Material Weakness Significant Deficiency

Finding 2022-002 U.S. Department of Education Student Financial Assistance Cluster: Federal Direct Student Loans, Assistance Listing 84.268 Federal Pell Grant, Assistance Listing 84.063 Federal Work Study Program, Assistance Listing 84.033 Federal Supplemental Education Opportunity Grants, Assi...

Finding 2022-002 U.S. Department of Education Student Financial Assistance Cluster: Federal Direct Student Loans, Assistance Listing 84.268 Federal Pell Grant, Assistance Listing 84.063 Federal Work Study Program, Assistance Listing 84.033 Federal Supplemental Education Opportunity Grants, Assistance Listing 84.007 Teacher Education Assistance For College and Higher Education Grants, Assistance Listing 84.379 P268K220568, P063P210568, P033A212492, P007A212492, P379T220568 Special Test and Provisions ? Return of Title IV Funds Material Weakness in Internal Control over Compliance Finding Summary: In the current year, there was no evidence of an independent review over the return of Title IV calculations. Responsible Individuals: Maia Rowland, Student Financial Aid Director Corrective Action Plan: This issue will cease to exist in the future due to the acquisition of SNU by UNR. The acquisition of SNU by UNR was effective July 1, 2022. Anticipated Completion Date: This issue will cease to exist in the future due to the acquisition of SNU by UNR. The acquisition of SNU by UNR was effective July 1, 2022.

View Audit 64382

Finding 72361 (2022-001)

Significant Deficiency 2022

Town of Stoneham, Massachusetts

MA

Period of Performance Allowable Costs / Cost Principles Reporting § 200.309

2022-001 Special Education Cluster ? CFDA No. 84.027 and 84.173 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: None. Action taken in response...

2022-001 Special Education Cluster ? CFDA No. 84.027 and 84.173 Recommendation: We recommend procedures be implemented to ensure that all costs charged to the grant are incurred within the grant period of performance. Explanation of disagreement with audit finding: None. Action taken in response to finding: The School district paid for goods/services after the performance period of the grant. All purchase orders and invoices for payment are reviewed by the Town Wide Budget director before posting or processing. This review is to ensure compliance with local, state and federal laws and regulations. Name(s) of the contact person(s) responsible for corrective action: David Ljungberg, Superintendent and Leia Secor, and Town Wide Budget Director Planned completion date for corrective action plan: Procedure currently in place.

View Audit 64380

Finding 72324 (2022-001)

None 2022

William Marsh Rice University

TX

Student Financial Aid Matching / Level of Effort / Earmarking

Management accepts the recommendation to request from students receiving federal financial assistance voluntary consent to participate in electronic transactions. The Corrective Action Plan is as follows: Effective December 1, 2022, the University added language to its NetID and other communicatio...

Management accepts the recommendation to request from students receiving federal financial assistance voluntary consent to participate in electronic transactions. The Corrective Action Plan is as follows: Effective December 1, 2022, the University added language to its NetID and other communication portals outlining the policy and obtaining a student?s consent for electronic transactions. 1. The Voluntary Consent for Electronic Transactions was added to our consumer information page. https://financialaid.rice.edu/forms-resources/consumer-information 2. The Voluntary Consent for Electronic Transactions was added to the https://mynetid.rice.edu/ page. Effective Date: December 1, 2022 Person responsible for implementation: Paul Negrete, Executive Director for University Financial Aid Services, 713-348-5905

View Audit 63485

Finding 72315 (2022-002)

Significant Deficiency 2022

Huntington Theatre Company, Inc. and Affiliates

MA

Eligibility Significant Deficiency

January 25, 2023 Cognizant or Oversight Agency for Audit The Huntington Theatre Company, Inc. and Affiliates respectfully submits the following corrective action plan for the fiscal year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAS 50 Washington Street Westbor...

January 25, 2023 Cognizant or Oversight Agency for Audit The Huntington Theatre Company, Inc. and Affiliates respectfully submits the following corrective action plan for the fiscal year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAS 50 Washington Street Westborough, MA 01581 Audit period: July 1, 2021 - June 30, 2022 The findings from the January 25, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. SMALL BUSINESS ADMINISTRATION 2022-002 COVID-19 - Shuttered Venue Operators Grant Program - Assistance Listing #59,075 Recommendation: Procedures should be implemented requiring the completion of required forms and the formal review and approval should be performed prior to adding employees to payroll Action Taken: Management takes this extremely seriously and will bring in temporary support staff in order to bring all accounts fully up to date and to implement new systems and practices according to these recommendations. If the U.S. Small Business Administration has questions regarding this plan, please call Michael Maso at 617-273-1526.

View Audit 62784

Finding 71815 (2022-003)

Significant Deficiency 2022

Shawnee State University

OH

Allowable Costs / Cost Principles Significant Deficiency

Finding Number: 2022-003 Condition: The University charged unallowable payroll expenditures to the grant as they were for payroll costs and related employee benefits that were not for costs newly associated with coronavirus or to prevent, prepare for, or respond to coronavirus. Planned Corrective Ac...

Finding Number: 2022-003 Condition: The University charged unallowable payroll expenditures to the grant as they were for payroll costs and related employee benefits that were not for costs newly associated with coronavirus or to prevent, prepare for, or respond to coronavirus. Planned Corrective Action: Shawnee State University has discontinued charging salaries to the HEERF award. Any potential new salaries or payments for services will be reviewed and evaluated by the Program Director to certify that the expenses are costs newly associated with coronavirus or to prevent, prepare for, or respond to coronavirus. Contact person responsible for corrective action: Greg A Ballengee, Controller Anticipated Completion Date: 10/6/2022

View Audit 64280

Finding 71812 (2022-002)

Material Weakness 2022

Shawnee State University

OH

Student Financial Aid Material Weakness Reporting

Finding Number: 2022-002 Condition: Shawnee State University did not report student status changes timely and accurately for certain students who graduated or withdrew during the year. Planned Corrective Action: Prior to an enrollment report being uploaded to the National Student Clearinghouse, the ...

Finding Number: 2022-002 Condition: Shawnee State University did not report student status changes timely and accurately for certain students who graduated or withdrew during the year. Planned Corrective Action: Prior to an enrollment report being uploaded to the National Student Clearinghouse, the Recalculate Academic Record process in our student information system, currently J1, will be ran to identify any student registration records that may be stuck in a current status due to a mixed Repeat status. Those records will be corrected as needed. The office underwent major staffing changes, which caused a delay in submitting reports in a timelier manner. The staffing issues have been resolved and reports are uploaded on the scheduled submission date. Contact person responsible for corrective action: Tamara Sheets Anticipated Completion Date: 10/6/2022

View Audit 64280

Finding 71811 (2022-001)

Material Weakness 2022

Shawnee State University

OH

Student Financial Aid Material Weakness Matching / Level of Effort / Earmarking

Finding Number: 2022-001 Condition: The University did not return title IV funds to the Department of Education within the required time frame for certain students who required a return of funds and did not identify all students initially that required a return of title IV. Planned Corrective Action...

Finding Number: 2022-001 Condition: The University did not return title IV funds to the Department of Education within the required time frame for certain students who required a return of funds and did not identify all students initially that required a return of title IV. Planned Corrective Action: Upon notification of Finding No. 2021-003, a new R2T4 process was created for the Spring 2022 academic term. This process consists of a new report created to identify students who withdrew from all courses during each academic term. Once the R2T4 calculation is completed, the aid adjustment is made in the financial aid system and posted to the student's account the same day. The aid amounts are manually adjusted in COD. All errors related to finding No. 2022-001 are from Summer 2021 academic term and the Fall 2021 academic term. There were no errors in the audit sample for Spring 2022. The new process continues to be in place. Contact person responsible for corrective action: Nicole Neal Anticipated Completion Date: 10/6/2022

View Audit 64280

Finding 71799 (2022-002)

Significant Deficiency 2022

One Community Health

OR

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

Corrective action plan: OCH Human Resources is reviewing the organization?s bonus policy to include exception, the policy will also include the process for post approval adjustments. Planned completion date is December 31, 2022.

View Audit 62045

Finding 71670 (2022-001)

Significant Deficiency 2022

Marbles Kids Museum

NC

Allowable Costs / Cost Principles § 200.406

2022-001 Shuttered Venue Operations Grant ? Assistance Listing No. 59.075 Recommendation: We recommend management implement a process to ensure expenditures applied to the grant are net of applicable credits. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...

2022-001 Shuttered Venue Operations Grant ? Assistance Listing No. 59.075 Recommendation: We recommend management implement a process to ensure expenditures applied to the grant are net of applicable credits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Federal grants awarded to Marbles Kids Museum are typically monitored by a team ? including individuals from accounting, development, and the learning & exhibits department ? which meets regularly to discuss progress on the grant and review expenses which are recorded under a unique account in the general ledger system. The Shuttered Venue Operators Grant differed from our usual federal grants in several respects: It allowed expenses that were incurred up to 15 months prior to the date of the award; the grant was not for a specific program but to cover specific operational costs to sustain the organization through the COVID-19 pandemic; and the grant was managed by the accounting department. Going forward all federal grants will be reviewed by a group consisting of at least 2 departments familiar with the expenses, with one department being the accounting department. In addition, all credits from vendors that are used for federal grants will be reviewed to confirm they are not related to items originally purchased for a federal grant. If the credit is related to an expense allocated to a federal grant the credit will be netted against the expense. Name(s) of the contact person(s) responsible for corrective action: April Ward, VP of Finance Planned completion date for corrective action plan: March 31, 2023

View Audit 66361

Finding 71663 (2022-005)

Significant Deficiency 2022

Operation Samahan, Inc.

CA

Allowable Costs / Cost Principles Material Weakness Significant Deficiency

2022-005 Allowable Costs Corrective action planned: HR is keeping track of and documenting all salary raises and as part of procedure, filling out form (Personnel Action Form) prepared by HR and signed by the CEO every time a raise is given. The form will be put in the employee file. Anticipated com...

2022-005 Allowable Costs Corrective action planned: HR is keeping track of and documenting all salary raises and as part of procedure, filling out form (Personnel Action Form) prepared by HR and signed by the CEO every time a raise is given. The form will be put in the employee file. Anticipated completion date: July 2022 Contact person responsible for corrective action: Lita Santos, HR Director

View Audit 65450

Finding 71662 (2022-004)

Material Weakness 2022

Operation Samahan, Inc.

CA

Special Tests & Provisions Material Weakness Significant Deficiency

2022-004 Special Tests and Provisions Corrective action planned: In December 2022, the clinic reviewed and updated the clinic?s Sliding Fee Discount Program as well as the clinic?s fee schedule for 2023. We have trained staff and will be doing regular monitoring. We have made income and family size ...

2022-004 Special Tests and Provisions Corrective action planned: In December 2022, the clinic reviewed and updated the clinic?s Sliding Fee Discount Program as well as the clinic?s fee schedule for 2023. We have trained staff and will be doing regular monitoring. We have made income and family size mandatory fields in the demographics field and requested that ECW to make sliding fee a mandatory field with a hard stop. Our data analyst is running regular reports to check if sliding fee is being done correctly with the billing liaison?s regular check of patient charts and billing, Policies and Procedures include monitoring of the Sliding Fee Discount Program. The billing liaison will randomly choose five charts from each clinic site to test patients? discount application, patient eligibility (income and family size), proof of income, and application of the appropriate sliding fee discount. Anticipated completion date: December 2022 Contact person responsible for corrective action: Elizabeth David, Finance Director

View Audit 65450

Finding 71661 (2022-003)

Material Weakness 2022

Operation Samahan, Inc.

CA

Allowable Costs / Cost Principles Material Weakness Reporting

2022-003 Reporting (repeat finding of 2021-003) Corrective action planned: The UDS reporting is made more accurate by using not only ECW reporting capabilities, but also by getting an i2i population health data tool as a secondary verification platform for UDS data, alongside a competent data analys...

2022-003 Reporting (repeat finding of 2021-003) Corrective action planned: The UDS reporting is made more accurate by using not only ECW reporting capabilities, but also by getting an i2i population health data tool as a secondary verification platform for UDS data, alongside a competent data analyst. the finance department and our project coordinator. The team will oversee gathering all pertinent demographics and financials needed from the clinic?s patient management software (ECW) and accounting software (Sage Intacct). The team attended the 2022 UDS Reporting and Technical Assistance Webinar series sponsored by Department of Public Health Care/Health Resources and Services Administration to ensure the team has the latest update and changes to the 2022 UDS Reporting. The Clinic has also upgraded the patient management software (ECW) to the latest version and is now UDS + (UDS modernization Initiative) ready. Anticipated completion date: December 31, 2022 Contact person responsible for corrective action: Archie Bella, CEO; Roberto Bautista, Data Analyst; Elizabeth David, Finance Director

View Audit 65450

Finding 71658 (2022-001)

None 2022

Southwestern Adventist University

TX

Eligibility Reporting

Corrective Action: We made a quarterly report of the HEERF fund and this information is updated on the University webpage: https://swau.edu/coronavirus-information/. Contact Person: Carlos Charnichart, Financial Vice President Completion Date: Spring 2023.

View Audit 65445

Finding 71657 (2022-002)

None 2022

Southwestern Adventist University

TX

Questioned Costs Student Financial Aid Eligibility

Corrective Action: New student information system has processes in place that will prevent over awarding/over payments, assisting reduce human error. Contact Person: Duane Valencia, Assistant Financial Vice President Completion Date: Began School year 22-23, ongoing

View Audit 65445 Questioned Costs: $1

Finding 71653 (2022-003)

Significant Deficiency 2022

Southwestern Adventist University

TX

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

Corrective Action: We have hired additional full-time staff who is being trained and will be overseeing the document requirements for student files. Contact Person: Duane Valencia, Assistant Financial Vice President Completion Date: In progress, staff hired Spring ?23. Currently in training, on...

Corrective Action: We have hired additional full-time staff who is being trained and will be overseeing the document requirements for student files. Contact Person: Duane Valencia, Assistant Financial Vice President Completion Date: In progress, staff hired Spring ?23. Currently in training, ongoing.

View Audit 65445

Finding 71652 (2022-005)

Significant Deficiency 2022

Menominee Tribal Enterprise

WI

The Enterprise acknowledges that collateral has not been obtained in the past for all funds. The Enterprise will work with their financial institutions to collateralize all funds.

View Audit 64573

Finding 71651 (2022-004)

Significant Deficiency 2022

Menominee Tribal Enterprise

WI

Reporting Internal Control / Segregation of Duties

The Enterprise acknowledges an oversight on the delay in filing the SF-425. Management will implement processes to submit within the 90 day deadline.

View Audit 64573

Corrective Action Plans

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