Corrective Action Plans

Name of Contact Person: Paula Terbrak, City Treasurer. Recommendation: We recommend the City develop written policies and procedures related to cash management, cost allowability, procurement, and conflict of interest provisions for federal funds it receives. Corrective Action: We will adopt ap...

Name of Contact Person: Paula Terbrak, City Treasurer. Recommendation: We recommend the City develop written policies and procedures related to cash management, cost allowability, procurement, and conflict of interest provisions for federal funds it receives. Corrective Action: We will adopt appropriate policies as soon as possible. Proposed Completion Date: Immediately.

View Audit 319179

Finding 496232 (2024-001)

Significant Deficiency 2024

Lakefront Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 27, 2023.

View Audit 319176

Finding 496230 (2024-001)

Significant Deficiency 2024

MacArthur Manor Senior Residences, Inc.

KS

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Statement of condition #2024-001: The Corporation used reserve for replacements funds for a non-approved purpose. Comments on the Finding and Each Recommendation: Management should reimburse the reserve for replacements fund all excess funds withdrew. Action(s) taken or planned on the finding: Man...

Statement of condition #2024-001: The Corporation used reserve for replacements funds for a non-approved purpose. Comments on the Finding and Each Recommendation: Management should reimburse the reserve for replacements fund all excess funds withdrew. Action(s) taken or planned on the finding: Management refunded $2,717 to reserve for replacement account on August 13, 2024.

View Audit 319175 Questioned Costs: $1

Finding 496228 (2024-001)

Significant Deficiency 2024

Southern Hills Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 31, 2023.

View Audit 319174

Finding 496226 (2024-001)

Significant Deficiency 2024

Woodlake Senior Residences, Inc.

KS

Subrecipient Monitoring HUD Housing Programs Reporting

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...

Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 30, 2023.

View Audit 319173

Finding 486147 (2024-001)

None 2024

Hudson Senior Housing, Inc.

MN

Questioned Costs HUD Housing Programs

Hudson Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd., 1000 Shelard Parkway, Suite 110, Minneapolis, MN 55426 Audit Period: March 31, 2024; The ...

Hudson Senior Housing, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd., 1000 Shelard Parkway, Suite 110, Minneapolis, MN 55426 Audit Period: March 31, 2024; The findings from the March 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed.FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT - FINDING 2024-001: SECTION 202, ASSISTANCE LISTING NUMBER 14.157 The Project overpaid management fees by $809. Recommendation: The management company should reimburse the Project for the $809 overpayment. Action Taken: The Project agrees with the finding. The accounting staff will be reminded to be careful when calculating management fees. If the Department of Housing and Urban Development has questions regarding this plan, please call Chuck Reuter at 651-645-7271.

View Audit 318793 Questioned Costs: $1

Finding 486138 (2024-001)

None 2024

Worthington Senior Housing, Inc.

MN

Auditor RecommendationRecommendation: We recommend that the Organization ensure that the required deposit to the reserve for replacements account be made on a timely basis. Corrective Action Plan (CAP)1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding....

Auditor RecommendationRecommendation: We recommend that the Organization ensure that the required deposit to the reserve for replacements account be made on a timely basis. Corrective Action Plan (CAP)1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding.2. Action Planned in Response to Finding Sara Wohlers (management agent) will ensure that deposits to reserve for replacements account are made on a timely basis when cash allows. The remaining deposit for the June 30, 2024 fiscal year was deposited on July 22, 2024.3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for ensuring corrective action of the deficiency.4. Planned Completion Date for CAP This plan will be implemented for the June 30, 2025 audit.5. Plan to Monitor Completion of CAP Chuck Reuter (Accounting Manager) and Sara Wohlers will be monitoring this plan.

View Audit 318784

Finding 486130 (2024-003)

Significant Deficiency 2024

Village of Shelby

MI

Equipment & Real Property Management

Finding 2024-003: Community Development Block Grants Type of Finding: Both Control and Compliance U.S. Department of Housing and Urban Development Pass-through Entity: Michigan Strategic Fund Assistance Listing Number: 14.228 Award Numbers: MSC 22003-PGS and MSC-221009-WRI Award Year Ends: No...

Finding 2024-003: Community Development Block Grants Type of Finding: Both Control and Compliance U.S. Department of Housing and Urban Development Pass-through Entity: Michigan Strategic Fund Assistance Listing Number: 14.228 Award Numbers: MSC 22003-PGS and MSC-221009-WRI Award Year Ends: November 30, 2024, and December 31, 2024 Recommendation: The Village should establish procedures to require the maintenance of detailed fixed asset records that include all specified elements. In addition, the Village should perform a physical inventory of the property and reconcile the results with fixed asset records at least once every two years to help prevent loss, damage, or theft of the property. Action Taken: The Village will establish a standard operating procedure that requires the maintenance of detailed asset records and the performance of a documented physical inventory of the assets acquired with federal funds on an annual basis. Responsible Person and Anticipated Completion Date: The Village Clerk/Treasurer will oversee the implementation of this plan by February 28, 2025. If the Michigan Strategic Fund has questions regarding this plan, please call Crystal Budde at 231-861-4401.

View Audit 318759

Finding 486104 (2024-002)

Significant Deficiency 2024

Abilene Christian University

TX

Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking

Responsible Individual: Tamara Long Vice President for Enrollment and Student Engagement Abilene Christian University Finding 2024-002 Special Tests & Provisions - Bonus & Incentives Related to Enrollment Agency Name: U.S. Deparlment of Education Program Name: Federal Pell Grant, Federal Direct Stud...

Responsible Individual: Tamara Long Vice President for Enrollment and Student Engagement Abilene Christian University Finding 2024-002 Special Tests & Provisions - Bonus & Incentives Related to Enrollment Agency Name: U.S. Deparlment of Education Program Name: Federal Pell Grant, Federal Direct Student Loans, SEOG, Federal Work Study and TEACH Grants August 19, 2024 Finding Summary: Incentive Compensation (34 CFR 668.14(b)(22)(i) Institutions are required, within the Program Participation Agreement (PPA), to acknowledge that they will not provide any commission, bonus, or other incentive payment based on any part, directly or indirectly, upon success in securing enrollments or awards of financial aid. The university documented several bonus payments to individuals related to enrollment strategies and goals. Corrective Action Plan (CAP): Based on the findings of the Special Tests and Provisions for Incentive Compensation as part of (34 CFR668.14(b)(22}(i), the offices of enrollment and financial operations have identified additional review and controls that will be put in place to mitigate future risk of non-compliance. Additional review will be required by a financial operations member for any requests made for enrollment related staff. In addition, a formal tenure bonus structure has already been put in place to ensure that no bonuses or incentives are given based on enrollment goals. Anticipated Completion Date: As the tenured bonus structure has already been activated, the review of bonuses raises, and incentive pay will immediately be required to go through an additional financial review for compliance. The anticipated completion date is July 1, 2024

View Audit 318751 Questioned Costs: $1

Finding 486102 (2024-001)

Significant Deficiency 2024

Abilene Christian University

TX

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

Responsible Individual: Eric Gumm Registrar and Director of First Year Program and Academic Development Center Abilene Christian University Finding 2024-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans August...

Responsible Individual: Eric Gumm Registrar and Director of First Year Program and Academic Development Center Abilene Christian University Finding 2024-001 concerning Enrollment Reporting Agency Name: U.S. Department of Education Program Name: Federal Pell Grant, Federal Direct Student Loans August 19, 2024 Finding Summary: Enrollment Reporting (34 CFR 690.93(b)(2); 34 CFR 682.610; 34 CFR 685.309) Institutions are required to report enrollment information. The University's processes did not ensure timely and accurate student status reporting to National Student Loan Data System (NSLDS). Out of the population of 829 students with student attendance changes required to be reported, a sample of 25 students were selected for testing. The University failed to report 3 students who had changes in enrollment status. Of the three students the University failed to report, 2 students had withdrawn from the University. The University reported the incorrect enrollment effective dates for 3 students at the program and campus levels. The University failed to report graduated status for 2 students (students were reported as withdrawn and the University failed to subsequently update the status to graduated). The University reported the incorrect Program Enrollment Effective Date for 1 student. The University did not report a change in enrollment status in a timely manner for 1 student. Corrective Action Plan (CAP): Based on the findings within the Federal and State Financial Assistance Program audit, it was determined that a significant deficiency exists within the review of reporting for student enrollment through the National Student Loan Data System (NSLDS). The office of Student Financial Services has identified the need for regular reconciliation of updates to student enrollment status from the Banner point of record to the NSLDS system. Our plan of action begins with a comprehensive understanding of the roles and responsibilities between the financial aid office and the registrar's office. Once this is well documented, the Office of the Registrar will begin a monthly reconciliation of enrollment reporting for any student status changes that have happened within that month. Anticipated Completion Date: The timeline for this CAP begins with the formal documentation of the enrollment reporting process. This will take place prior to the start of the Fall 2024 semester. The reconciliation of reporting will begin in September 2024 after 12th day of enrollment is confirmed and sent to the Clearinghouse for updates. The anticipated completion date is July 1, 2024

View Audit 318751

Finding 486076 (2024-001)

Significant Deficiency 2024

Enterprise Valley Medical Clinic

UT

Ongoing training/internal audits will be done monthly to be more robust and ensure staff understands and accurately calculate which discount the patient qualifies for. EVMC Administrative Assistant and Clinical Manager shall review the slide audits to determine which employees are making errors and ...

Ongoing training/internal audits will be done monthly to be more robust and ensure staff understands and accurately calculate which discount the patient qualifies for. EVMC Administrative Assistant and Clinical Manager shall review the slide audits to determine which employees are making errors and provide re-training or corrective action as applicable and document/monitor for improvement. Staff will also notice slide on patients eligibility form match what is on the slide in patient’s electronic chart. We have also put the date at the top of our sliding fee eligibility form so that we are using correct forms.

View Audit 318717

Finding 486020 (2024-003)

Material Weakness 2024

Central Michigan University Research Corporation

MI

Subrecipient Monitoring § 200.332

Corrective Action Plan: Management will review the required procedures for pass-through entities as listed in 2 CFR 200.332 and implement the procedures accordingly. This will include documented risk assessment and monitoring procedures for all subrecipient of federal awards.

View Audit 318710

Finding 485975 (2024-001)

Significant Deficiency 2024

Omni Residence, Inc.

TX

Recommendation: Management should institute procedures to ensure that the Data Collection Form is electronically filed with the Federal Audit Clearinghouse within nine months of year end. View of Responsible Officials: Management will implement procedures to ensure that the form is timely submitted ...

Recommendation: Management should institute procedures to ensure that the Data Collection Form is electronically filed with the Federal Audit Clearinghouse within nine months of year end. View of Responsible Officials: Management will implement procedures to ensure that the form is timely submitted in the future.

View Audit 318693

Finding 485891 (2024-001)

Significant Deficiency 2024

Mainline Health Systems, INC

AR

Special Tests & Provisions

Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2024 Finding #2024-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s...

Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2024 Finding #2024-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding and management has implemented procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Office Managers will review all new sliding fee application on a monthly basis to ensure accuracy. The Billing Manager will conduct quarterly audits of sliding fee claims to ensure the adjustments are entered correctly by the billing department. The Organization has also launched additional training for all individuals involved in the sliding fee application process as well as automated sliding fee adjustments to reduce errors.

View Audit 318629

Finding 485833 (2024-001)

Significant Deficiency 2024

Mainline Health Systems, INC

AR

Special Tests & Provisions

Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2024 Finding #2024-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s...

Name: Mainline Health Systems, Inc. Contact Name: Elyse Knobloch Contact Phone Number: 870.538.5414 Auditor/Audit Firm: Forvis Mazars, LLP Audit Period: January 31, 2024 Finding #2024-001 – Statement of Condition Patients did not receive the proper sliding fee adjustments under the Organization’s policy. Response: The Organization concurs with the finding and management has implemented procedures to ensure that eligible patients receive discounts in accordance with the sliding fee scale. The Office Managers will review all new sliding fee application on a monthly basis to ensure accuracy. The Billing Manager will conduct quarterly audits of sliding fee claims to ensure the adjustments are entered correctly by the billing department. The Organization has also launched additional training for all individuals involved in the sliding fee application process as well as automated sliding fee adjustments to reduce errors.

View Audit 318624

Finding 485764 (2024-002)

Significant Deficiency 2024

Mountain Famly Health Centers

CO

Procurement, Suspension & Debarment

Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over the documentation of sole source/non-competitive bid justification prior to contracting with a vendor using federal ...

Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over the documentation of sole source/non-competitive bid justification prior to contracting with a vendor using federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has accepted the recommendation and will add language to the existing Purchasing and Procurement Guidance Policy and Procedure outlining the requirement for documentation of sole source/noncompetitive bid justification. In instances where the item or service is only available from one source or competition is deemed inadequate, the Organization will keep written documentation of justification for sole source. Also, the Organization will educate supervisors on this policy update at an upcoming training meeting no later than October 31, 2024. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Steve Leazer, CFO, at 970-945-2840.

View Audit 318603

Finding 485762 (2024-001)

Material Weakness 2024

Mountain Famly Health Centers

CO

Subrecipient Monitoring § 200.331

Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over sub-grant recipient procedures and create effective internal controls and procedures over subrecipient monitoring an...

Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over sub-grant recipient procedures and create effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable Federal laws, regulations, and compliance requirements of various Federal grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has accepted the recommendation and will add language to the existing Grant Funds Tracking Policy and Procedure outlining the Organization’s responsibilities for establishing effective internal controls and procedures over subrecipient monitoring. The updated policy will also include reference to the Information to Provide to Every Subrecipient for Each Subaward form. This form outlines details of the pass-through grant, and subrecipient responsibilities, and will be signed by each subrecipient prior to any pass-through fund disbursement. Also, the Organization will educate supervisors on this policy update at an upcoming training meeting no later than October 31, 2024.

View Audit 318603

Finding 485748 (2024-001)

Significant Deficiency 2024

Lockport Housing Authority

NY

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Auditee Response: The Authority will not pay any invoices until the proper documentation of Davis Bacon wages being paid is received from the contractor. The Authority will then be ensured that future payments have the proper certified payroll.

View Audit 318581

Finding 485729 (2024-001)

None 2024

New Hampshire Catholic Charities

NH

Reporting

Timeliness of Reporting - Federal Agency: U.S. Department of Health and Human Services; Award Name: Consolidated Appropriations Act – NH Food Bank Mobile Food Pantries; Program Year: 2024; ALN #: 93.493. Criteria: Management was responsible for submitting timely reporting based on the terms of th...

Timeliness of Reporting - Federal Agency: U.S. Department of Health and Human Services; Award Name: Consolidated Appropriations Act – NH Food Bank Mobile Food Pantries; Program Year: 2024; ALN #: 93.493. Criteria: Management was responsible for submitting timely reporting based on the terms of the grant agreement. Condition: During compliance testing, it was identified that the required Federal Financial Report (FFR) was not submitted timely to the Payment Management System (PMS). Context: The required FFR was not submitted timely based on the terms of the grant agreement. Cause: Management has processes and controls over the reporting process but experienced difficulty in obtaining access to PMS resulting in a delayed FFR submission. In an email dated March 26, 2024, a PMS Alert was issued from Congressionally Directed Community Projects. The PMS Alert stated that "PMS is reporting substantial delays in establishing access to accounts, due to increased fraudulent activities. They have indicated that a 30-day delay on access may be common." Management reports that the process took well over 30 days. Effect: As a result of the condition, the Organization's required reporting was not submitted timely based on the terms of the grant agreement. Recommendation: In the future, the Organization should ensure it implements appropriate processes and controls to ensure required reports are filed timely in accordance with the terms of the grant agreement. Contact: David Hildenbrand, Chief Financial Officer. Corrective Actions Taken or Planned: Management acknowledges the finding and will ensure controls are implemented to prevent this error from reoccurring. Anticipated Completion Date: By December 31, 2024.

View Audit 318556

Finding 485658 (2024-004)

Material Weakness 2024

Four Rivers Special Education District

IL

Internal Control / Segregation of Duties

CONDITION: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. RECOMMENDATION: The District should segregate duties where possible. The board should be aware of this problem and closely review and approve all financia...

CONDITION: The District's accounting function is controlled by a limited number of individuals resulting in the inadequate segregation of duties. RECOMMENDATION: The District should segregate duties where possible. The board should be aware of this problem and closely review and approve all financial related information. ACTION TAKEN: The District concus with the recommendation. The District has reviewed and continues to review its financial policies and procedures to better segregate duties where possible. The Director continually reminds the board of their responsibility in regards to reviewing and approving financial items and asking questions. It is not cost feasible to hire additional personnel. ANTICIPATED DATE OF COMPLETION: Ongoing.

View Audit 318470

Corrective Action Plans

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