Corrective Action Plans

Finding 524275 (2024-001)

Significant Deficiency 2024

UT

Procurement, Suspension & Debarment

Our corrective action plan is to address the Federal Awards Findings, 2024-001: Procurement and Suspension and Debarment - Compliance Finding. It was the Company's understanding that the grant monies were Utah State-related and not under the Federal requirements. We were notified by the State in Apr...

Our corrective action plan is to address the Federal Awards Findings, 2024-001: Procurement and Suspension and Debarment - Compliance Finding. It was the Company's understanding that the grant monies were Utah State-related and not under the Federal requirements. We were notified by the State in April 2024 that we were considered as subrecipients. The Comapny accountant, Dallen Henderson, will work with Company secretary, Kay Meikle, to verify vendors are not debarred or suspended and will report back to the General Manager, Rick Smith, to meet the requirements. As this funding continues, we will do this process annually and-or when we add a new contractor/vendor.

View Audit 343471

Finding 524274 (2024-001)

Significant Deficiency 2024

Lancaster Area Habitat for Humanity, Inc.

PA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency § 200.302

Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Andrew Szalay The root of this “significant finding” has been among the Program staff capturing receipts for small expenditures, such as water and ice, and such, from convenient stores, during construction with Habitat volu...

Anticipated Completion Date: January 31, 2025 Responsible Contact Person: Andrew Szalay The root of this “significant finding” has been among the Program staff capturing receipts for small expenditures, such as water and ice, and such, from convenient stores, during construction with Habitat volunteers. These were all credit card receipts. In the fall of 2024, Habitat management have conducted two types of meetings to ensure source documentation is collected and submitted with financial records: 1. Individual conversations with every credit card holder about the importance of turning in receipts, no matter how small, documentation is critical. 2. Goup meeting with the “frequent offenders” and further emphasized the importance of turning in receipts. Credit card holders were warned that credit card privileges may be revoked if the problem continues. In addition, additional tools may be put into place to capture and retain documentation. This may include vendor apps and digital upload tools. Policies will also be reviewed to ensure practices and terms are consistent and clear for both credit card holders and other staff that submit expense reimbursement forms.

View Audit 343464 Questioned Costs: $1

Finding 524273 (2024-001)

Significant Deficiency 2024

Starmont Community School District

IA

Internal Control / Segregation of Duties

Internal control deficiencies: See Finding 2024-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is n...

Internal control deficiencies: See Finding 2024-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible.

View Audit 343453

Finding 524262 (2024-005)

Significant Deficiency 2024

City of Newcastle

WY

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

#2024-005 FINDING: Written Uniform Guidance Policies Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will develop written policies for activities allowed or unallowed, allowable costs/cost principles, and procurement and suspension and debarment. Anticipated...

#2024-005 FINDING: Written Uniform Guidance Policies Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will develop written policies for activities allowed or unallowed, allowable costs/cost principles, and procurement and suspension and debarment. Anticipated Completion Date: Ongoing

View Audit 343442

Finding 524259 (2024-004)

Material Weakness 2024

City of Newcastle

WY

Procurement, Suspension & Debarment

#2024-004 FINDING: Procurement, Suspension, and Debarment Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will implement policies to obtain quotes from a reasonable number of vendors prior to expending federal funds when the acquisition exceeds $10,000 and w...

#2024-004 FINDING: Procurement, Suspension, and Debarment Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City will implement policies to obtain quotes from a reasonable number of vendors prior to expending federal funds when the acquisition exceeds $10,000 and will also verify that the vendors have not been suspended/debarred. Anticipated Completion Date: Ongoing

View Audit 343442

Finding 524254 (2024-001)

Material Weakness 2024

City of Newcastle

WY

Reporting Internal Control / Segregation of Duties

#2024-001 FINDING: Financial Statement and SEFA Preparation Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City has accepted the risk associated with Finding #2024-001 regarding the preparation of the financial statements and SEFA and will continue to have the i...

#2024-001 FINDING: Financial Statement and SEFA Preparation Responsible Individuals: Stacy Haggerty, Clerk/Treasurer Corrective Action Plan: The City has accepted the risk associated with Finding #2024-001 regarding the preparation of the financial statements and SEFA and will continue to have the independent auditor prepare the annual financial statements. Anticipated Completion Date: Ongoing

View Audit 343442

Finding 524225 (2024-003)

Material Weakness 2024

Cherokee Communith School District

IA

Internal Control / Segregation of Duties

SEE EXPLANATION AND CORRECTIVE ACTION PLAN AT 2024-001

View Audit 343427

Finding 524224 (2024-002)

Significant Deficiency 2024

Staywell Healthcare, Inc.

CT

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Dir...

2024.02 - Eligibility Recommendation We recommend that management provide training to those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken 1) To ensure patient eligibility is properly assigned to patients, the Director of Clinical Operations will perform random audits on a Monthly basis of patients that are assigned. 2) The Director of Clinical Operations will also ensure proper training to those that are assigning eligibility to ensure that proper documentation is obtained and properly stored. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Eric Newman, CFO at (203) 756-8021 x 3015. Sincerely yours, Eric Newman Chief Financial Officer

View Audit 343418

Finding 524220 (2024-001)

Significant Deficiency 2024

Staywell Healthcare, Inc.

CT

Special Tests & Provisions Subrecipient Monitoring Eligibility

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will ass...

SIGNIFICANT DEFICIENCY 2024.001 - Sliding Fee Scale Discount Recommendation The Center should implement a system of controls to ensure all sliding fee discounts are properly supported. Action Taken 1) To ensure Sliding Fee Discounts are properly supported, the Director of Program Management will assign random audits on a Monthly basis of patients that are assigned a sliding fee. 2) Director of Program Management as well as Program Managers will monitor Phreesia dashboard to identify self-pay patients on the schedule and work to ensure that accounts are updated accordingly. a. For any accounts that need to be updated, they will inform the PSA who checked in the patient to make the updates as necessary and provide additional training if needed. b. Provide trainings to PSAs to ensure that they are offering the Sliding Fee Discount to all patients that may need to apply, and appropriately applying those slides. 3) If a Pt has had a visit and left prior to getting sliding fee information, PSAs are to call the patient to let them know that they may have to apply for a sliding fee (or receive insurance information over the phone). 4) Practice Managers will identify Self-pay accounts via Phreesia each morning that may need attention and send a list of accounts to the PSAs at the beginning of each day. PSA will then contact the patients to remind them to bring in proof of income to apply for the sliding fee if eligilble.

View Audit 343418

Finding 524217 (2024-001)

None 2024

Exeter-West Greenwich Regional School District

RI

Questioned Costs § 200.344

Corrective Action Plan-In our commitment to due diligence and adherence to compliance requirements for the expenditure of funds from a federal grant, the School District contacted the responsible representatives at the Rhode Island Department of Education (RIDE) to seek guidance on establishing a mu...

Corrective Action Plan-In our commitment to due diligence and adherence to compliance requirements for the expenditure of funds from a federal grant, the School District contacted the responsible representatives at the Rhode Island Department of Education (RIDE) to seek guidance on establishing a multi-year contract for curriculum materials. The budget description submitted to RIDE for approval indicated that the School District adopted the Bridge program in March 2024. It detailed that the associated expenses would be incurred under a six-year contract covering licenses and consumables, classified as High-Quality Curriculum Materials. This expense received both programmatic and budgetary approval from the Rhode Island Department of Education.Moving forward, the School District will request all supporting documentation to ensure compliance to the laws and regulations governing any federal or state grant.Anticipated Completion Date – June 30th, 2025Contact Person – If you have any additional questions, please feel free to contact me.Taisabel Lopez,District Treasurer401-397-5125 x 2021Taisabel_Lopez@ewg.k12.ri.us

View Audit 343413 Questioned Costs: $1

Finding 524213 (2024-007)

Significant Deficiency 2024

Montcalm Community College

MI

Procurement, Suspension & Debarment § 200.214

2024-007 – Procurement, Suspension and Debarment. Auditor Description of Condition and Effect. During our testing of disbursements, it was noted that the College did not follow their procurement policy for purchases over the micro purchase threshold and there is no procedure in place to determine wh...

2024-007 – Procurement, Suspension and Debarment. Auditor Description of Condition and Effect. During our testing of disbursements, it was noted that the College did not follow their procurement policy for purchases over the micro purchase threshold and there is no procedure in place to determine whether vendors are suspended or debarred. Certain vendors could be used that are considered suspended or debarred by the federal government resulting in noncompliance. Auditor Recommendation. We recommend that the College implement a policy over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable, and to follow their procurement policy when entering into purchases greater than the micro purchase threshold. Corrective Action. College to create a procedure that will require a vendor search to determine if vendors are listed as suspended or debarred, or otherwise excluded from participating, before engaging with them. In addition, the college will remind employees involved in purchasing that they must follow the college’s threshold regarding amounts of purchases. Responsible Party. Connie Stewart, SR VP & COO will create and implement new policy. Anticipated Completion Date. As soon as practicable but no later than February 28, 2025.

View Audit 343397

Finding 524210 (2024-006)

Significant Deficiency 2024

Montcalm Community College

MI

Matching / Level of Effort / Earmarking Student Financial Aid Reporting § 200.303

2024-006 – Common Origination and Disbursement (COD) Reporting. Auditor Description of Condition and Effect. During our testing of COD reporting, we identified one of 40 disbursements was not reported to COD within 15 days of the disbursement date. A lack of timely reporting may prevent the College ...

2024-006 – Common Origination and Disbursement (COD) Reporting. Auditor Description of Condition and Effect. During our testing of COD reporting, we identified one of 40 disbursements was not reported to COD within 15 days of the disbursement date. A lack of timely reporting may prevent the College and other schools from having the most accurate student information which may lead to over awards. Auditor Recommendation. We recommend that the College evaluate and enhance its procedures and policies around reporting disbursements to COD to ensure that student information is reported accurately and timely. Corrective Action. I have a procedure in place to report graduates as soon as they are confirmed with academics. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. January 2025.

View Audit 343397

Finding 524208 (2024-005)

Significant Deficiency 2024

Montcalm Community College

MI

Student Financial Aid Allowable Costs / Cost Principles Eligibility

2024-005 – Pell Grant Calculation. Auditor Description of Condition and Effect. One student out of the twenty five Pell grants tested was found to be under awarded based on the enrollment status and cost of attendance. As a result of this condition, the College was exposed to an increased risk that ...

2024-005 – Pell Grant Calculation. Auditor Description of Condition and Effect. One student out of the twenty five Pell grants tested was found to be under awarded based on the enrollment status and cost of attendance. As a result of this condition, the College was exposed to an increased risk that incorrect information would be used to determine students' Pell Grant award amounts. Auditor Recommendation. We recommend the College implement procedures to ensure the COA and EFC used to calculate each student's Pell Grant is updated for each academic year and reviewed by an independent official. Corrective Action. This is corrected on setup and noted to correct the COA. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. March 2025 - next set up, it was corrected for 24/25 academic year in May 2024.

View Audit 343397

Finding 524203 (2024-004)

Significant Deficiency 2024

Montcalm Community College

MI

Student Financial Aid Reporting Significant Deficiency

2024-004 – Fiscal Operations Report and Application to Participate (FISAP) Reporting. Auditor Description of Condition and Effect. It was noted during our testing of the FISAP that the College did not have support for one of the eight key line items identified in the compliance supplement as critica...

2024-004 – Fiscal Operations Report and Application to Participate (FISAP) Reporting. Auditor Description of Condition and Effect. It was noted during our testing of the FISAP that the College did not have support for one of the eight key line items identified in the compliance supplement as critical information. The College is not in compliance with the Department of Education requirements that state the FISAP must be accurately reporting information. Auditor Recommendation. We recommend the College review their policies and procedures surrounding FISAP reporting. Corrective Action. Adjust notes on the procedure (or guidelines), laying out the complete steps of FISAP to ensure the data is accurate. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. February 2025 - the next FISAP.

View Audit 343397

Finding 524198 (2024-003)

Significant Deficiency 2024

Montcalm Community College

MI

Reporting Special Tests & Provisions Student Financial Aid

2024-003 – Timeliness of Status Change Reporting. Auditor Description of Condition and Effect. It was noted during our testing of 13 students with status changes, two instances of late reporting of status changes. Both of these instances were fall graduates whose status change was not reported withi...

2024-003 – Timeliness of Status Change Reporting. Auditor Description of Condition and Effect. It was noted during our testing of 13 students with status changes, two instances of late reporting of status changes. Both of these instances were fall graduates whose status change was not reported within the required timeframe. As a result of this condition, the NSLDS had incorrect records of the enrollment status of students. Auditor Recommendation. We recommend the College reviews the status change reporting requirements and implement procedures to ensure that the status changes are being reported to the NSLDS in a timely manner. Corrective Action. To view graduated student's as soon as they have been processed. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. November 2024.

View Audit 343397

Finding 524193 (2024-002)

Significant Deficiency 2024

Montcalm Community College

MI

Special Tests & Provisions Student Financial Aid Reporting

2024-002 – Return of Title IV (R2T4) Calculation. Auditor Description of Condition and Effect. During our testing of six students with Return of Title IV amounts, we noted that the College did not exclude the correct amount of days for scheduled breaks of five days or more in both the fall 2023 and ...

2024-002 – Return of Title IV (R2T4) Calculation. Auditor Description of Condition and Effect. During our testing of six students with Return of Title IV amounts, we noted that the College did not exclude the correct amount of days for scheduled breaks of five days or more in both the fall 2023 and spring 2024 terms, resulting in the incorrect Return of Title IV calculation for all students tested. As a result of this condition, the students' return of funds calculation was not done correctly and the return of funds back to the federal government was for the incorrect amount. Auditor Recommendation. We recommend the College review the Return of Title IV requirements and implement procedures to ensure the Return of Title IV calculations are using the correct amount of term days and are completed accurately. Corrective Action. This has been noted in setup notes, so the number of days are correct going forward. Responsible Party. Financial Aid Director, Jennifer Stimson. Anticipated Completion Date. November 2024.

View Audit 343397

Finding 524187 (2024-002)

Significant Deficiency 2024

Umatilla Morrow Head Start, Inc.

OR

Reporting § 200.510

Schedule of Expenditures of Federal Awards (SEFA) Preparation Corrective Action Plan As part of the year-end closing process and in preparation for the audit, UMHS finance department was understaffed and to help in the interim, CLA was hired to add capacity and help with accounting functions for U...

Schedule of Expenditures of Federal Awards (SEFA) Preparation Corrective Action Plan As part of the year-end closing process and in preparation for the audit, UMHS finance department was understaffed and to help in the interim, CLA was hired to add capacity and help with accounting functions for UMHS, including the SEFA. The auditors noted that the SEFA had been provided to them without proper review by the management of UM HS. In response, UM HS reviewed the SEFA for fiscal year 2024. Going forward, UMHS is adding more staff capacity to the finance department and recently hired two new experienced finance team members with knowledge in payroll, AP and procurement. Additionally, UMHS initiated recruitment for a permanent Director of Finance in summer 2024 and the search to hire for this position is open and ongoing. If in the future a third-party consultant or firm is secured by UMHS, the organization will prepare entries, reports, or schedules for UMHS management and will thoroughly review and approve all items to ensure accuracy prior to submission to the auditors. Timing for Implementation: Immediate and Ongoing Person(s) Responsible: Executive Director, Director of Finance, or Other Designee

View Audit 343360

Finding 524186 (2024-001)

Material Weakness 2024

Umatilla Morrow Head Start, Inc.

OR

Internal Control / Segregation of Duties Material Weakness Reporting § 200.302

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. recently added capacity and experience to the finance department by hiring two new staff members, a Payroll Specialist and an AP and Procurement Specialist. In addition, best practices and reconciliati...

Reconciliations and Material Adjustments Corrective Action Plan Umatilla Morrow Head Start, Inc. recently added capacity and experience to the finance department by hiring two new staff members, a Payroll Specialist and an AP and Procurement Specialist. In addition, best practices and reconciliation timelines and guidance are being captured in financial policies and procedures being updated at this time. UMHS has also implemented new software tools that will assist in automating the department, providing additional time for staff members to implement a monthly review that includes reconciliations and tracking. This "internal auditing" process is relatively new to the department and will add a layer of accountability and accuracy in the recording and processing of the organization's financial activity. In addition, UMHS initiated recruitment for a permanent Director of Finance in summer 2024 and the search to hire for this position is open and ongoing. To supplement and support the current staff, UMHS will continue to provide additional training and guidance to the finance team to stay ahead of changes to federal and state guidelines, and to build on the knowledge and experience of the team. Adding a permanent Director of Finance will be essential as that staff member will be a member of the Senior Leadership Team and working in supporting and staffing the monthly Finance Committee meetings and supporting the UMHS Board of Directors' Treasurer. UMHS Senior Leadership Team will review and approve year-end financial schedules being provided to the auditors, as well as provide additional oversight and approval of year-end entries and closing processes. Timing for Implementation: Immediate and Ongoing Person(s) Responsible: Executive Director, Director of Finance, or Designee

View Audit 343360

Finding 524171 (2024-001)

Material Weakness 2024

Louisiana Delta Service Corps

LA

Internal Control / Segregation of Duties Cash Management Reporting § 200.303

Management Response: Due to the size of LDSC’s administrative staff, complete segregation of duties is not economically feasible. We will ensure the areas recommended above are added to our current policy to the extent it is economically feasible.

View Audit 343346

Finding 524170 (2024-002)

Significant Deficiency 2024

United Way of Tucson and Southern Arizona, Inc.

AZ

Subrecipient Monitoring § 200.332

The Organization concurs with the finding and will implement the following: Develop additional policies and procedures that require documentation of subrecipient monitoring including a risk assessment for each subrecipient Revise all federal subrecipient contracts to include federal award identifica...

The Organization concurs with the finding and will implement the following: Develop additional policies and procedures that require documentation of subrecipient monitoring including a risk assessment for each subrecipient Revise all federal subrecipient contracts to include federal award identification number and the amount of federal funds awarded to each subrecipient Distribute policies and procedures and contract templates to all applicable finance and programmatic staff Train staff on the new policies and procedures

View Audit 343343

Finding 524169 (2024-001)

Significant Deficiency 2024

United Way of Tucson and Southern Arizona, Inc.

AZ

Procurement, Suspension & Debarment

The Organization concurs with the finding and will implement the following: Develop additional policies and procedures that require documentation for the method of procurement and the Organization's procedures for verifying its chosen vendor Distribute policies and procedures to all applicable finan...

The Organization concurs with the finding and will implement the following: Develop additional policies and procedures that require documentation for the method of procurement and the Organization's procedures for verifying its chosen vendor Distribute policies and procedures to all applicable finance and programmatic staff Train staff on the new policies and procedures

View Audit 343343

Finding 524163 (2024-005)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Reporting Internal Control / Segregation of Duties

Condition: We noted that six of the quarterly expenditure reports were not filed in a timely manner. There were expenses with dates on them that should have been reported in earlier quarter reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ens...

Condition: We noted that six of the quarterly expenditure reports were not filed in a timely manner. There were expenses with dates on them that should have been reported in earlier quarter reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that all quarterly expenditure reports are filed by the due dates. Management Response: Management will take the necessary steps to file all quarterly reports on time in the future.

View Audit 343341

Finding 524162 (2024-007)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and th...

Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting.

View Audit 343341

Finding 524161 (2024-006)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Equipment & Real Property Management Procurement, Suspension & Debarment

Condition: Equipment records were not maintained for items purchased with federal funds. Recommendation: We will provide the ISBE equipment log guidelines and recommend that the District begins the process of maintaining a log going forward for all equipment purchased with federal funding. We also ...

Condition: Equipment records were not maintained for items purchased with federal funds. Recommendation: We will provide the ISBE equipment log guidelines and recommend that the District begins the process of maintaining a log going forward for all equipment purchased with federal funding. We also recommend the District obtains a grant equipment spending policy. Management Response: Management agrees to take the necessary steps to ensure compliance requirements are met and will discuss implementing an inventory record-keeping process.

View Audit 343341

Finding 524160 (2024-004)

Significant Deficiency 2024

Madison Commuity Unit School District #12

IL

Reporting

Condition: The District claimed expenses early on the 6/30/24 expenditure report that should have been reported as outstanding obligations. Recommendation: We recommend adding a verification process to reconcile the general ledger totals using the check dates to the ISBE expenditure reports before...

Condition: The District claimed expenses early on the 6/30/24 expenditure report that should have been reported as outstanding obligations. Recommendation: We recommend adding a verification process to reconcile the general ledger totals using the check dates to the ISBE expenditure reports before submitting. Management Response: The District will add a verification process to reconcile the general ledger totals using the check dates to the expenditure reports before submitting.

View Audit 343341

Corrective Action Plans

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