Corrective Action Plans

Finding 521186 (2024-002)

Significant Deficiency 2024

Western Piedmont Regional Transit Authority

NC

Reporting Subrecipient Monitoring Significant Deficiency

Name of Contact Person: Scott Cook Corrective Action/Management’s Response: WPRTA will timely submit the Transportation Asset Management (TAM) inventory report. Proposed Completion Date: Immediately and ongoing

View Audit 341148

Finding 521185 (2024-006)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to e...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management.

View Audit 341140

Finding 521184 (2024-005)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc. will review their process for reviewing and approving reimbursement requests. Completion Date: The Center implemented an internal control in October 2023 to ensure all reimbursement reques...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc. will review their process for reviewing and approving reimbursement requests. Completion Date: The Center implemented an internal control in October 2023 to ensure all reimbursement requests are reviewed and approved by management.

View Audit 341140

Finding 521183 (2024-004)

Significant Deficiency 2024

Domestic Violence Crisis Center

ND

Cash Management Internal Control / Segregation of Duties

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to e...

Contact Person: Kathryn Cowart, Board President Corrective Action Plan: Domestic Violence Crisis Center, Inc.’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. Completion Date: The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management.

View Audit 341140

Finding 521182 (2024-001)

Significant Deficiency 2024

Housing Authority of Lake City

SC

Questioned Costs HUD Housing Programs Allowable Costs / Cost Principles

2024-001 ALN 14.871 – Housing Voucher Cluster – Activities Allowed or Unallowed The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Questioned Costs. In 2021, the Authority was instructed by Keith Landrum of the Colu...

2024-001 ALN 14.871 – Housing Voucher Cluster – Activities Allowed or Unallowed The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Questioned Costs. In 2021, the Authority was instructed by Keith Landrum of the Columbia, South Carolina HUD Field Office to stop making payments until the matter could be further investigated to see what amounts, if any, are still owed. Management will continue to monitor budgets to ensure that funds are adequate. Management has and will continue to make budget revisions to reduce unessential operating costs. The Authority has designed and implemented a Board approved formal repayment agreement. Person Responsible for Correction of Finding: Mark Fountain, Executive Director Projected Completion Date: June 30, 2025

View Audit 341129 Questioned Costs: $1

Finding 521180 (2024-002)

Significant Deficiency 2024

Natrona County School District No. 1

WY

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

The District will adopt a general ledger account structure that is directly correlated to the Wyoming Department of Education’s Accounting Manual.

View Audit 341125

Finding 521164 (2024-001)

Material Weakness 2024

Southwestern Child Development Commission, Inc.

NC

Matching / Level of Effort / Earmarking Special Tests & Provisions Procurement, Suspension & Debarment

Finding 2024-001 - Employee Record Retention and Health and Safety Training Federal Program: CCDF Cluster: AL# 93.575 - Child Care and Development Block Grant AL# 93.596 - Child Care Mandatory and Matching Funds of the CCDF U.S. Department of Health and Human Services MATERIAL WEAKNESS NONCO...

Finding 2024-001 - Employee Record Retention and Health and Safety Training Federal Program: CCDF Cluster: AL# 93.575 - Child Care and Development Block Grant AL# 93.596 - Child Care Mandatory and Matching Funds of the CCDF U.S. Department of Health and Human Services MATERIAL WEAKNESS NONCOMPLIANCE Special Tests and Provisions Name of Contact Person: Juanita Dillard Corrective Action: As of January 2024, all childcare centers operated by the Organization have been closed. Health and safety training courses will no longer be required. Completion Date: January 31, 2024

View Audit 341119

Finding 521162 (2024-003)

Significant Deficiency 2024

Eastern Wyoming College

WY

Student Financial Aid Allowable Costs / Cost Principles Reporting

Corrective actions: The Financial Aid Office has historically received a copy of the Fund 10 and Fund 13 ledgers from the Business Office and then calculated the tuition and fees, making sure to remove the concurrently enrolled students and inapplicable fees. This calculation was completed without k...

Corrective actions: The Financial Aid Office has historically received a copy of the Fund 10 and Fund 13 ledgers from the Business Office and then calculated the tuition and fees, making sure to remove the concurrently enrolled students and inapplicable fees. This calculation was completed without knowledge that some of the Fund 13 Fees pass through and are already included the Fund 10 details. This resulted in a number of Fund 13 Fees being counted twice. This process has been corrected starting with the 24-25 FISAP. The CFO and Financial Aid Director worked together and the CFO calculated the tuition and fees for Part II Section E of the FISAP. This ensured the correct calculation and eliminated the inclusion of fees that were flowing through the two different GL fund accounts. Anticipated completion date: September 30,2024 Contact person: Rebecca McAllister/Kwin Wilkes

View Audit 341116

Finding 521160 (2024-002)

Significant Deficiency 2024

Eastern Wyoming College

WY

Student Financial Aid Reporting Significant Deficiency

Corrective actions: Eastern Wyoming College currently has a service arrangement with National Student Clearinghouse (NSC) to provide enrollment reporting to the National Student Loan Data System (NSLDS) per the requirements outlined in CFR 690.83 (b)(2), 685.309(b), and per the NSLDS Enrollment Repo...

Corrective actions: Eastern Wyoming College currently has a service arrangement with National Student Clearinghouse (NSC) to provide enrollment reporting to the National Student Loan Data System (NSLDS) per the requirements outlined in CFR 690.83 (b)(2), 685.309(b), and per the NSLDS Enrollment Reporting Guide. These regulations require institutions to report changes in enrollment within a 60-day period. In fulfilling these requirements, EWC's Data Analyst utilizes reports in Colleague to complete the enrollment reporting requirements and submit these reports to NSC. This occurs every thirty days, which exceeding meets the 60-day requirement. EWC's Office of Institutional Research, through the Data Analyst, works with the Registrar and the Financial Aid Office to review and resolve any reporting errors with NSC. Historically, this process worked with minimal errors, but the HCM2 processes posed some unforeseen challenges in the reporting process. To meet these challenges, the Data Analyst sends the student rosters to the NSC. If the students on the SSCR roster are not part of the NSLDS database as a current borrower or recipient of federal student aid, then the Data Analyst must manually upload the information to the NSLDS instead of relying on NSC to initiate the reporting. The Student Financial Aid and Registrar Offices have implemented controls to ensure the proper and timely reporting of student status changes. Upon the implementation of an effective reporting control process, EWC will directly review the student status changes at the NSLDS rather than rely solely on its third-party service provider. For instances where students program length was not reporting correctly, this was resolved at the end of 2022-2023 award year, and the Financial Aid office updated all the Colleague screens used to pull the reports utilized by Institutional Research in submitting the report. EWC has developed and distributed Standard Operating Procedures to ensure the withdrawal dates reported in each office are using the same information. Anticipated completion date: October 2024 Contact person: Rebecca McAllister/Xi Feng

View Audit 341116

Finding 521157 (2024-003)

Significant Deficiency 2024

Hamilton Health Center, Inc.

PA

Questioned Costs Cash Management Allowable Costs / Cost Principles

Condition The Organization's negotiated indirect cost rate agreement includes a provisional rate of 17.75% of direct costs for the period April 1, 2021 through March 21, 2024. The Organization charged indirect costs to its American Rescue Plan supplemental health center funding using a rate of 18.8...

Condition The Organization's negotiated indirect cost rate agreement includes a provisional rate of 17.75% of direct costs for the period April 1, 2021 through March 21, 2024. The Organization charged indirect costs to its American Rescue Plan supplemental health center funding using a rate of 18.8% of direct costs for the period April 2023 through June 2023. The 18.8% rate that was used was obtained from an expired indirect cost rate agreement. Corrective Action Plan Corrective Action Planned: The continued use of the expired indirect cost rate was caused by the departure of the CFO who was responsible for reviewing federal grant draw downs. After the CFO left, the controller continued using the expired indirect cost rate but now the new CFO has put in place a system of review the indirect cost rate in effect against all reports before drawing down the grant. Name(s) of Contact Person(s) Responsible for Corrective Action: Frackson Sakala, CFO; Joseph McLaughlin, Controller; and Tran Le, the Assistant Controller. Anticipated Completion Date: This was immediately effected when this error was discovered during the FY2024 audit.

View Audit 341112 Questioned Costs: $1

Finding 521156 (2024-002)

Significant Deficiency 2024

Hamilton Health Center, Inc.

PA

Reporting Internal Control / Segregation of Duties

Condition The Organization was required to submit thirty-five reports during its fiscal year ended March 31, 2024, which comprised six financial reports and twenty-nine performance reports. Two performance reports and three financial reports were not filed timely. Reports that were filed late range...

Condition The Organization was required to submit thirty-five reports during its fiscal year ended March 31, 2024, which comprised six financial reports and twenty-nine performance reports. Two performance reports and three financial reports were not filed timely. Reports that were filed late ranged from being 1 day late up to seventeen days late. The Organization was able to demonstrate its attempt to file 4 of the late reports before their respective due dates however due to login issues on the federal submission site, the reports were not timely filed. The fifth late submission was late by one day. Corrective Action Plan Corrective Action Planned: The late submission of some grant reports was mainly due to login issues when the HRSA changed the process for logging in by adding on a second layer for authentication. A diary system has been developed to alert the CFO and the Controller when grant reports are due. Also, the Controller and Assistant Controller have been given access to both the Payment Management System and the Electronic Handbook (EHB) and have been trained in federal grant reporting so that in the absence of one the others can prepare the reports and submit in time. Name(s) of Contact Person(s) Responsible for Corrective Action: Frackson Sakala, CFO; Joseph McLaughlin, Controller; and Tran Le, the Assistant Controller Anticipated Completion Date: This has been started and is expected to be completed by January 31, 2025.

View Audit 341112

Finding 521153 (2024-002)

Significant Deficiency 2024

Isd # 13 Columbia Heights

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties School Nutrition Programs

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553, 10.555, AND 10.559) 2024-002 Internal Control Over Compliance With Federal Suspension and Debarment Requireme...

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE – PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER (FEDERAL ALN 10.553, 10.555, AND 10.559) 2024-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the child nutrition cluster. The District did not have sufficient controls in place within its child nutrition cluster to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Actions Planned – The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – Bryan Hennekens, Director of Finance and Operations. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – Bryan Hennekens, Director of Finance and Operations, will work with the financial auditors to review specific weaknesses identified during the annual audit and actions needed to eliminate or mitigate this internal control weakness.

View Audit 341108

Finding 521152 (2024-001)

None 2024

Big Brothers Big Sisters of Central Ohio, Inc. & Subsidiaries

OH

Subrecipient Monitoring Cash Management Reporting

Finding Number: 2024-001 Condition: The Organization failed to submit monthly reimbursement requests to the Franklin County Department of Job and Family Services by their due dates during the year ended June 30, 2024. Planned Corrective Action: The Organization, effective the anticipated completio...

Finding Number: 2024-001 Condition: The Organization failed to submit monthly reimbursement requests to the Franklin County Department of Job and Family Services by their due dates during the year ended June 30, 2024. Planned Corrective Action: The Organization, effective the anticipated completion date cited in prior year CAP plan, 4/30/2024, has implemented system and process improvements to ensure timely submission. The Organization has and will continue to maintain appropriate staffing level and sufficient training to ensure timely submission. This plan does not account for circumstances beyond BBBSCO’s control such as timing of funding approval from Franklin County. Non-controllable delays will be documented by BBBSCO and reports submitted in a reasonable amount of time following approval. Contact Person Responsible for Corrective Action: Elizabeth Martinez, President and CEO Anticipated Completion Date: January 31, 2025

View Audit 341106

Finding 521151 (2024-004)

Material Weakness 2024

Granite Vna, Inc.

NH

Questioned Costs Allowable Costs / Cost Principles

Corrective Action Planned: Management will certify that the costs charged to grants are documented, reviewed and approved for accuracy and legitimacy. Individual Responsible for Corrective Action: Jim Manahan, CFO Anticipated Completion Date: CFO will implement immediately.

View Audit 341103 Questioned Costs: $1

Finding 521131 (2024-003)

Material Weakness 2024

Sheridan Community Schools

IN

Questioned Costs Allowable Costs / Cost Principles School Nutrition Programs § 200.303 § 200.403 § 200.430

FINDING 2024-003 Finding Subject: Child Nutrition Cluster (School Lunch) – Allowable Cost Summary of Finding: The payroll for non-certified employees for the 2023-2024 school year has not been approved by the board, leading to a lack of verification for salaries paid from fund 800. As a result, any ...

FINDING 2024-003 Finding Subject: Child Nutrition Cluster (School Lunch) – Allowable Cost Summary of Finding: The payroll for non-certified employees for the 2023-2024 school year has not been approved by the board, leading to a lack of verification for salaries paid from fund 800. As a result, any payroll for non-certified employees paid after August 1, 2023 from fund 800 cannot be verified. Contact Person Responsible for Corrective Action: Robin Popejoy Contact Phone Number and Email Address: 317.758.4172 – rpopejoy@sheridan.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The salary schedules will be submitted to the board for approval. Anticipated Completion Date: May – August 2025

View Audit 341082 Questioned Costs: $1

Finding 521130 (2024-005)

Material Weakness 2024

Sheridan Community Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Eligibility § 200.303

FINDING 2024-005 Finding Subject: Child Nutrition Cluster (School Lunch) – Eligibility Summary of Finding: Café Director uploaded the Direct Certification reports from the state into the software system without following a documented oversight or review process to ensure that direct certified studen...

FINDING 2024-005 Finding Subject: Child Nutrition Cluster (School Lunch) – Eligibility Summary of Finding: Café Director uploaded the Direct Certification reports from the state into the software system without following a documented oversight or review process to ensure that direct certified students were accurately processed. This highlights a lack of documented controls for directly certified students. Contact Person Responsible for Corrective Action: Robin Popejoy Contact Phone Number and Email Address: 317.758.4172 – rpopejoy@sheridan.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Data Department will collaborate with the Café Department to input and ensure the accuracy of the information. Anticipated Completion Date: Already started in August of 2024.

View Audit 341082

Finding 521129 (2024-004)

Material Weakness 2024

Sheridan Community Schools

IN

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.303

FINDING 2024-004 Finding Subject: Child Nutrition Cluster (School Lunch) – Suspension and Debarment Summary of Finding: One of the vendors tested did not have documentation showing that the school corporation had verified they were not suspended or debarred before entering into a covered transaction...

FINDING 2024-004 Finding Subject: Child Nutrition Cluster (School Lunch) – Suspension and Debarment Summary of Finding: One of the vendors tested did not have documentation showing that the school corporation had verified they were not suspended or debarred before entering into a covered transaction. Contact Person Responsible for Corrective Action: Robin Popejoy Contact Phone Number and Email Address: 317.758.4172 – rpopejoy@sheridan.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Café Direction will check SAM.gov to ensure the vendor is not suspended or debarred before proceeding with any transactions. Anticipated Completion Date: January 2025

View Audit 341082

Finding 521128 (2024-001)

None 2024

Calvary Towers, INC

VA

Eligibility

Management will ensure that tenant files will retain all necessary documentation and required forms to substantiate eligibility and compliance with rent procedures. Files will not be purged of any documentation that supports tenant's eligibility. Anticipated completion date: January 22, 2025. Respon...

Management will ensure that tenant files will retain all necessary documentation and required forms to substantiate eligibility and compliance with rent procedures. Files will not be purged of any documentation that supports tenant's eligibility. Anticipated completion date: January 22, 2025. Responsible Contact Person: Michelle N. Thomas, Property Manager

View Audit 341077

Finding 521110 (2024-001)

Material Weakness 2024

Deliverance Manor Housing Corporation

IL

Questioned Costs Student Financial Aid Cash Management

CORRECTIVE ACTION PLAN Finding No. 2024-001: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be pos...

CORRECTIVE ACTION PLAN Finding No. 2024-001: Credit Card was not reconciled and receipts were not obtained. Expenses were not properly recorded in the general ledger. Recommendation: Management should reconcile credit card accounts monthly and secure receipts for purchases and expenses should be posted to the proper general ledger account. Action Taken or Planned: Credit card accounts will be reconciled and receipts will be requested for purchases. Accounting will review the nature of purchases and properly post to the general ledger. Responsible Person: Mary Amador, Property Manager Completion Date: October 31, 2024

View Audit 341047 Questioned Costs: $1

Finding 521107 (2024-002)

Significant Deficiency 2024

Ravalli Head Start, Inc.

UT

Procurement, Suspension & Debarment

Regarding 2024-002 Expense Approval Documentation, the senior team, including Jill Hansen and I, have reviewed the Procurement Policies in our Accounting and Financial Policies and Procedure Manual and we will continue to require multiple levels of approval as explained in the existing policy. The p...

Regarding 2024-002 Expense Approval Documentation, the senior team, including Jill Hansen and I, have reviewed the Procurement Policies in our Accounting and Financial Policies and Procedure Manual and we will continue to require multiple levels of approval as explained in the existing policy. The proposed corrective action is first, to perform an internal audit to confirm that every expenditure in the current fiscal year has the appropriate written approvals. Second, the senior team will evaluate the reasonableness of the exact approvals in the current policy, with the goal of reducing the administrative burden on employees if possible and taking into consideration budget responsibility and materiality thresholds. I will be the point person regarding these corrective actions and these changes to our Accounting and Financial Policies and Procedure Manual, which will be effective 3/1/25, pending Policy Council and Board approval. We have updated all Senior and Fiscal Staff. Project Management Staff will be updated on 1/28/25,

View Audit 341036

Finding 521106 (2024-001)

Material Weakness 2024

Ravalli Head Start, Inc.

UT

Procurement, Suspension & Debarment HUD Housing Programs

The senior management team including the Executive Director, interim CFO Jill Hansen, and the Finance Committee of the Governing Board have reviewed and agree with the findings. Regarding the 2024-001 Procurement of Capital Projects, Jill Hansen and I are proposing the corrective action of adding ad...

The senior management team including the Executive Director, interim CFO Jill Hansen, and the Finance Committee of the Governing Board have reviewed and agree with the findings. Regarding the 2024-001 Procurement of Capital Projects, Jill Hansen and I are proposing the corrective action of adding additional communication requirements to the existing procedures, starting with a pre-bid internal meeting including the ED, CFO, and other appropriate mangers. We will also be creating a timeline of meetings to prepare and manage our capital budget for facilities, technology, and other needs where all participants will be educated on the appropriate bid procedures and policies. I will be the point person regarding these corrective actions and these changes to our Accounting and Financial Policies and Procedure Manual, which will be effective 3/1/25, pending Policy Council and Board approval. We have updated all Senior and Fiscal Staff. Project Management Staff will be updated on 1/28/25,

View Audit 341036

Finding 521105 (2024-004)

Material Weakness 2024

City of Auburn

CA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

The City has documented in its reporting procedures to ensure supporting financial information is kept with the submitted report. The report that was compiled to procedure the report in FY 2023-24 was overwritten as ongoing expenses were being tracked in the report. Anticipated Completion Date: Dece...

The City has documented in its reporting procedures to ensure supporting financial information is kept with the submitted report. The report that was compiled to procedure the report in FY 2023-24 was overwritten as ongoing expenses were being tracked in the report. Anticipated Completion Date: December 30, 2024 Responsible Contact Person: Gretchen Johnson, Finance Director

View Audit 341029

Finding 521104 (2024-003)

Material Weakness 2024

City of Auburn

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Planned Corrective Action: The City is aware it needs a contract administration process to capture the status of vendors prior to entering into a contract. The drafting of a procedure will include this component. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Gretchen Joh...

Planned Corrective Action: The City is aware it needs a contract administration process to capture the status of vendors prior to entering into a contract. The drafting of a procedure will include this component. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Gretchen Johnson, Finance Director

View Audit 341029

Finding 521103 (2024-002)

Material Weakness 2024

City of Auburn

CA

Allowable Costs / Cost Principles Material Weakness § 200.430

Planned Corrective Action: The City will ensure actual costs are charged to the program as part of the annual reporting process. Anticipated Completion Date: December 30, 2024 Responsible Contact Person: Gretchen Johnson, Finance Director

View Audit 341029

Finding 521078 (2024-001)

Significant Deficiency 2024

Gloucester County Special Services School District

NJ

Cash Management Period of Performance Internal Control / Segregation of Duties

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The traini...

In order to strengthen internal controls, the School District will train the staff responsible for reimbursement requests, final reports, and amendments as well as those responsible for purchasing for the grant to ensure that there is proper supporting documentation and grant management. The training will include but is not limited to: NJ Finance law, good business practice, as well as a review of the purchasing manual. After this training in completed, the business office will be responsible for the review of reimbursement requests, final reports, amendments and purchases, prior to completion and submission to ensure compliance with the grant requirements and purchasing laws.

View Audit 341013

Corrective Action Plans

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