Corrective Action Plans

Finding 573884 (2024-007)

Significant Deficiency 2024

MI

Cash Management Significant Deficiency

Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective...

Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that expenses listed in reports are supported by our books and records. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573883 (2024-006)

Significant Deficiency 2024

Northern Lakes Community Mental Health

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573882 (2024-005)

Material Weakness 2024

Northern Lakes Community Mental Health

MI

Reporting Subrecipient Monitoring Cash Management § 200.328

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes...

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573881 (2024-004)

Material Weakness 2024

Northern Lakes Community Mental Health

MI

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.320

Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that...

Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that the vendors were not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Corrective Action: Current Finance staff will ensure that procurement measures are followed and that vendors are not suspended or debarred or disqualified. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530 Questioned Costs: $1

Finding 573874 (2024-002)

Significant Deficiency 2024

Transit Authority of Northern Kentucky

KY

Procurement, Suspension & Debarment § 200.318

Finding 2024-002: Federal Transit Cluster – Procurement and Suspension and Debarment (Noncompliance and Significant Deficiency in Internal Control) Condition: In some procurement files, TANK had missing documentation of procurement history, missing required contract clauses, lack of evidence of cont...

Finding 2024-002: Federal Transit Cluster – Procurement and Suspension and Debarment (Noncompliance and Significant Deficiency in Internal Control) Condition: In some procurement files, TANK had missing documentation of procurement history, missing required contract clauses, lack of evidence of contractor responsibility determination and missing lobbying and Buy America certifications. Corrective Action: TANK implemented new procurement procedures and a revised checklist which outline and confirm all of the FTA-required clauses for any federal procurement. TANK documented and submitted procedures for obtaining signed lobbying and Buy America certifications in all procurements over $100,000/$150,000. TANK documented our procurement procedure which requires a responsibility determination to verify that contractors were not debarred or suspended from participating in federal awards by checking for System Award Management (SAM) certification. TANK included in the new procurement procedures an update of the record-keeping of procurement history to include elements such as rationale for the method of procurement; selection of contract type; reason for contractor selection or rejection; and basis for the contract price. Responsible Party: Lyndi Whiteker, Procurement Analyst Anticipated Completion Date: Complete and findings were closed between 7/19/2024-11/26/2024.

View Audit 364521

Finding 573867 (2024-001)

Significant Deficiency 2024

Transit Authority of Northern Kentucky

KY

Questioned Costs Cash Management § 200.305

Finding 2024-001: Federal Transit Cluster – Cash Management/Financial Management and Capacity (Noncompliance and Significant Deficiency in Internal Control) Condition: TANK staff drew down federal funds in advance of allowable expenditures and did not disburse the federal funds within the required t...

Finding 2024-001: Federal Transit Cluster – Cash Management/Financial Management and Capacity (Noncompliance and Significant Deficiency in Internal Control) Condition: TANK staff drew down federal funds in advance of allowable expenditures and did not disburse the federal funds within the required three business days. Corrective Action: TANK has worked with the FTA to address this finding. We have developed procedures for: adherence to federal regulations related to federal grants management, training of all staff involved in the management of federal grants, and identifying back-ups who are trained/educated on doing this work. The procedures include explicit instruction on federal drawdown procedures and timelines, ECHO Reimbursement procedures, cash management of federal funds and training plans/compliance associated with these drawdowns. The procedures have been accepted by the FTA and are now active. Repayment was made to the grant in May 2025 and no penalties were assessed. Responsible Party: Sutton Rowley, FP&A Manager Anticipated Completion Date: Complete and finding was closed on March 24, 2025.

View Audit 364521 Questioned Costs: $1

Finding 573860 (2024-001)

None 2024

Midd-West School District

PA

Subrecipient Monitoring Reporting

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.

View Audit 364515

Finding 573853 (2024-001)

Significant Deficiency 2024

Enterprisekc

KS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Corrective Action Plan 2024-001: Management has since performed the suspension and debarment check for the vendor and included the check in the contract file for all covered transactions. Anticipated Completion Date: July 2025 Contact Person: Jay Konomos, Pillar Leader

View Audit 364498

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Segregation of Duties

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Name of Contact Person: Chelsey Traeger, City Clerk

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.

View Audit 364494

Finding 573850 (2024-002)

Significant Deficiency 2024

City of Belview

MN

Internal Control / Segregation of Duties

Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 364494

Finding 573847 (2024-001)

Significant Deficiency 2024

City of Belview

MN

Auditor Prepared Financial Statements

View Audit 364494

Finding 573847 (2024-001)

Significant Deficiency 2024

City of Belview

MN

Name of Contact Person: Chelsey Traeger, City Clerk

View Audit 364494

Finding 573847 (2024-001)

Significant Deficiency 2024

City of Belview

MN

Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.

View Audit 364494

Finding 573847 (2024-001)

Significant Deficiency 2024

City of Belview

MN

Proposed Completion Date: The City Council will implement the above procedures immediately.

View Audit 364494

Finding 573843 (2024-002)

Significant Deficiency 2024

Winnebago County, Wisconsin

WI

Procurement, Suspension & Debarment Subrecipient Monitoring

Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: Ther...

Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County is working on reviewing policies and procedures and updating as necessary. Further, they have hired a Management Analyst to help with training and ensuring grant compliance. Name(s) of the contact person(s) responsible for correction action: Carol Van Gruensven Planned completion date for corrective action: Ongoing

View Audit 364493

Finding 573840 (2024-001)

Significant Deficiency 2024

Central Tribes of the Shawnee Area, Inc.

OK

Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328

Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.

View Audit 364487

Finding 573826 (2024-014)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 364483

Finding 573825 (2024-013)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573824 (2024-012)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 364483

Finding 573823 (2024-010)

Material Weakness 2024

Caddo County

OK

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 364483

Finding 573812 (2024-001)

None 2024

Franciscan Alliance, Inc.

IN

Procurement, Suspension & Debarment § 200.320

Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to ...

Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to promote sound business practices and effective internal controls across the organization through communication, training, and consistent enforcement of the Franciscan’s policies. The following are the Views and Corrective Action Plans of Management regarding the Schedule of Findings and Questioned Costs for the year ended December 31, 2024 for Franciscan. AUDIT FINDING 2024-001 – Compliance with Reporting Requirements MANAGEMENT’S RESPONSE: Management concurs that the sole source justification was not formally documented prior to the time of procurement. Franciscan’s procurement policy already includes clear criteria for sole source contracting, including the requirement that such procurements be supported by documented justification and approved by the Vice President Supply Chain. The policy outlines specific conditions under which sole source justification is permitted and requires Supply Chain to verify price reasonableness using benchmarking tools or known pricing data. CORRECTIVE ACTION PLAN: Franciscan implemented a new procurement software in the fourth quarter of 2024. The software has a required field for users to select if the procurement is sole-source and if it is, another required field activates for the user to provide a reason for sole-source. Once a procurement request is submitted by the user, the sourcing team reviews the request and verifies it has the appropriate approval if it is sole-sourced. RESPONSIBLE PERSONS: Sarah Burdick, Administrative Director Strategic Sourcing, Franciscan Alliance, Inc. COMPLETION DATE: December 2024

View Audit 364476

Finding 573792 (2024-003)

Significant Deficiency 2024

Catahoula Parish School Board

LA

Eligibility Internal Control / Segregation of Duties

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Depar...

Reference # and title: 2024-003 Controls and Compliance over Title I Targeting (Eligibility) Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I 84.010A 2024 Criteria or specific requirement: Title I, Part A of the Elementary and Secondary Education Act of 1965, as amended by Every Student Succeeds Act, requires eligibility to be determined based on the number of children ages 5 through 17 from low-income families. School Board management is required to review all total 118 Corrective Action Plan for Current Year Findings and Questioned Costs (Continued) For the Year Ended June 30, 2024 119 enrollment and low-income families’ data to ensure that the underlying data includes only students ages 5 through 17 and to certify that the eligibility calculations are complete and accurate. Condition found: Title I management completes and submits the Title I Targeting online to the Louisiana Department of Education (LDOE). The LDOE pre-populates the enrollment and number of low-income students in the Title I Targeting; however, these numbers are required to be reviewed and changed, if necessary, by the School Board. In reviewing the underlying data in determining eligibility for each school, it was noted that the School Board did not remove those students under age 5, which resulted in the ranking of schools to not be accurate. Corrective action planned: The School Board was unaware of the data file used needed to be reviewed; however, we will only include the accurate age band moving forward.

View Audit 364457

Finding 573785 (2024-005)

Material Weakness 2024

Catahoula Parish School Board

LA

School Nutrition Programs Cash Management Reporting

Reference # and title: 2024-005 Controls and Compliance over Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Titl...

Reference # and title: 2024-005 Controls and Compliance over Reporting Federal program and specific federal award identification: AL Number Award Year FEDERAL GRANTER/ PASS THROUGH GRANTOR/PROGRAM NAME United States Department of Education; passed through Louisiana Department of Education Title I 84.010A 2024 COVID-19 Education Stabilization Funds: Education Stabilization (ESSER II) 84.425D 2021 Education Stabilization (ESSER III) 84.425U 2021 United States Department of Agriculture; passed through Louisiana Department of Education Child Nutrition Cluster: School Breakfast Program 10.553 2024 National School Lunch Program 10.555 2024 Criteria or specific requirement: Good internal controls require that all requests for reimbursement submitted to the Louisiana Department of Education (LDOE) are adequately reviewed and approved either before submission or after submission, but in a timely manner, to ensure amounts reported are complete and accurate. Condition found: In testing a sample of a requests for reimbursements for the Child Nutrition Program and periodic expense reports for the Title I and ESSER programs the following was noted: Title I: Total expenditures per the general ledger did not agree to the amounts reported in the final periodic expense report, which resulted in the School Board over requesting $71,386. It was also noted there is no review and approval process by a second person over the periodic expense report submissions. Child Nutrition: Although there were no exceptions noted in the information submitted to LDOE, it was noted there is no review and approval process by a second person over the claims for reimbursement. Education Stabilization: Total expenditures per the general ledger did not agree to the amounts reported in the fiscal year end’s periodic expense report submission. It was also noted that the School Board had over requested $118,103 in the current fiscal year. There is no review and approval process by a second person over the periodic expense report submissions. In testing the special reporting for the ESSER program, it was noted that the School Board had not maintained the supporting documentation for this report and therefore could not be adequately tested. Corrective action planned: The School Board will correct this immediately. We were aware of the Title I and ESSER issues and had been in contact with LDOE to correct them. We were unaware of Child Nutrition needing someone to review and approve those claims; however, we will implement that requirement moving forward.

View Audit 364457

Corrective Action Plans

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