Corrective Action Plans

Finding 1157785 (2022-030)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Cash Management Internal Control / Segregation of Duties § 200.303

The Government concurs with the auditor's findings and recommendations. The Government of the Virgin Islands (GVI) is implementing significant reforms to strengthen financial accountability and improve internal controls within its agencies. The Executive Order directing CFOs of the Government agenci...

The Government concurs with the auditor's findings and recommendations. The Government of the Virgin Islands (GVI) is implementing significant reforms to strengthen financial accountability and improve internal controls within its agencies. The Executive Order directing CFOs of the Government agencies to report to the Department of Finance aims to streamline financial oversight and ensure that public funds are being managed effectively. The introduction of a Public Finance Policy to standardize procedures and ensure compliance with Cash Management regulations (including CFRs and other compliance rules) is an important step in maintaining transparency and minimizing financial risks across the various government agencies.

View Audit 369907

Finding 1157780 (2022-029)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303

The Government concurs with the auditor's findings and recommendations. OTAG has updated policies and procedures to address pre-award costs, scope of work, and payout to vendors to abide with the 90 days close out process. OTAG is training new personnel and monitoring implementation.

View Audit 369907 Questioned Costs: $1

Finding 1157778 (2022-027)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Cash Management § 200.303

The Government concurs with the auditor's findings and recommendations. OTAG was not able to complete the preparation and submission of the SF-270 report for Fiscal Year 2022. However, OTAG has developed a Policies and Procedures Manual for FY2023. In addition, a Reimbursement Specialist was hired t...

The Government concurs with the auditor's findings and recommendations. OTAG was not able to complete the preparation and submission of the SF-270 report for Fiscal Year 2022. However, OTAG has developed a Policies and Procedures Manual for FY2023. In addition, a Reimbursement Specialist was hired to ensure separation of duties in financial reporting.

View Audit 369907

Finding 1157766 (2022-024)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The Government concurs with the auditor's findings and recommendations. DOH will revise drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted. DOH will update drawdown SOPs for Fiscal Year 2...

The Government concurs with the auditor's findings and recommendations. DOH will revise drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted. DOH will update drawdown SOPs for Fiscal Year 2025, ensuring that all drawdown documentation includes a review confirmation. DOH will also incorporate this updated procedure into Federal Grants update training in December 2024 and make it accessible to all staff on Business Process Improvement SharePoint site.

View Audit 369907

Finding 1155421 (2022-008)

Material Weakness 2022

Headquarters Kansas, Inc.

KS

Cash Management Material Weakness Reporting § 200.302 § 200.400

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be ...

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.

View Audit 367706

Finding 1155271 (2022-003)

Material Weakness 2022

Comanche County Medical Center

TX

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hosp...

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

View Audit 367503 Questioned Costs: $1

Finding 1155242 (2022-008)

Material Weakness 2022

Defensewerx

FL

Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.403 § 200.412

We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.

View Audit 367461

Finding 1155238 (2022-004)

Material Weakness 2022

Defensewerx

FL

Cash Management

We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating programs that are on a cost reimbursement basis. We have addressed this finding to our government partners. Specific government par...

We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating programs that are on a cost reimbursement basis. We have addressed this finding to our government partners. Specific government partners have requested the continuation of cash advances in the manner which we have been operating. We have worked with the other government partners and have come up with an incremental funding plan based on needs that are appropriate in maintaining the operational requirements set forth by the awards. Periodically we updated the government partners on program funds that have been used or those funds that are excess.

View Audit 367461

Finding 1155086 (2022-004)

Material Weakness 2022

Hill Country Community Clinic, Inc.

CA

Cash Management

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.

View Audit 367389

Finding 1153884 (2022-001)

Material Weakness 2022

Monterey County Business Council

CA

Cash Management Reporting Significant Deficiency

Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over rep...

Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2022. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2022 audit by August 30, 2025. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111

View Audit 366960

Finding 576021 (2022-007)

None 2022

South Dakota Urban Indian Health, Inc.

SD

Cash Management § 200.305

2022 – 007: Cash Collateralization Condition: During our review of the Organization’s cash, it was noted that as of September 30, 2022, they have not collateralized cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation. Cash balances of $11,685,898 were uninsu...

2022 – 007: Cash Collateralization Condition: During our review of the Organization’s cash, it was noted that as of September 30, 2022, they have not collateralized cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation. Cash balances of $11,685,898 were uninsured at September 30, 2022. Unearned revenue was reported at approximately $10,704,037 which includes advance payments of Federal funds. Corrective Action Plan: Management will review options with their bank to have a cash collateralization agreement put in place.

View Audit 365905

Finding 575795 (2022-012)

Material Weakness 2022

Village of Coalton

OH

Cash Management Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.302 § 200.305

The funds from the project came from several different grant sources. Bills were due and our consultant DLZ advised us on how to pay these bills even if they were paid from grants other than from the correct grant sources.

View Audit 365765

Finding 575793 (2022-010)

Material Weakness 2022

Village of Coalton

OH

Cash Management Reporting Matching / Level of Effort / Earmarking

Again started before I got here. I did what I was told by DLZ our Consultant.

View Audit 365765

Finding 575768 (2022-003)

None 2022

Albuquerque Area Indian Health Board, Inc.

NM

Questioned Costs Cash Management Internal Control / Segregation of Duties § 200.302 § 200.305

View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered wh...

View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered when the Accounting Manager was in the process of preparing the SEFA schedule. The Accounting Manager disclosed this error to the auditor during the course of the audit. Corrective Action Plan Timeline AAIHB will consult with the Program Manager and awarding agency to determine the appropriate resolution of the excess drawdown within 30 days. AAIHB finance office has a process in place of reviewing drawdowns and monitoring expenses as grants approach the end of the project funding period. Designation of Employee Position Responsible for Meeting Deadline Accounting Manager and Finance Director

View Audit 365730 Questioned Costs: $1

Finding 575136 (2022-007)

Significant Deficiency 2022

City of Davis

CA

Cash Management

Finding Reference Number: SA2022-007 Compliance with Grant Invoicing Requirements AL Number: 20.205 Assistance Listing Title: Highway Planning and Construction Cluster Federal Agency: Department of Transportation Pass Through Entity: California Department of Transportation Federal Award Ide...

Finding Reference Number: SA2022-007 Compliance with Grant Invoicing Requirements AL Number: 20.205 Assistance Listing Title: Highway Planning and Construction Cluster Federal Agency: Department of Transportation Pass Through Entity: California Department of Transportation Federal Award Identification Number: ATPL-5238(068) • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Ryan Chapman, Public Works Director, Engineering and Transportation • Corrective Action Plan: The Public Works Engineering and Transportation department updated its standard operating procedure of Monitoring Federal Grant Funded Projects Invoicing section to include steps required for reimbursements with filing frequency of over six months. • Anticipated Completion Date: August 2025

View Audit 365226

Finding 575128 (2022-005)

Material Weakness 2022

City of Davis

CA

Cash Management § 200.305

Finding Reference Number: SA 2022-005 Cash Management – Drawdown of Grant Funds In Advance of Disbursement AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitl...

Finding Reference Number: SA 2022-005 Cash Management – Drawdown of Grant Funds In Advance of Disbursement AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-15-MC-06-0037, B-16-MC-06-0037, B-17-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037, B-21-MC-06-0037 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed and implemented a timeline of required actions for the program to ensure compliance with deadlines. Staff performs drawdowns of CDBG funding through HUD's IDIS online system monthly. Staff will now report the quarterly drawdowns and reconciliation in the Funds Projected/ Funds Drawn spreadsheet to improve monitoring and identification of problems early. This will increase the speed by which Davis spends down its credit line, and reduce gaps in expenditure recording between IDIS and the City's financial management system. In addition, an updated draw-down process, paired with quarterly reconciliation and reporting through the quarterly cash transaction report, will help staff correctly draw entitlement funds. • Anticipated Completion Date: June 30, 2024.

View Audit 365226

Finding 575125 (2022-002)

Material Weakness 2022

City of Davis

CA

Cash Management HUD Housing Programs Matching / Level of Effort / Earmarking

Finding Reference Number: SA 2022-002 Cash Management AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housin...

Finding Reference Number: SA 2022-002 Cash Management AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-15-MC-06-0037, B-16-MC-06-0037, B-17-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037, B-21-MC-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed and implemented a timeline of required actions for the program to ensure compliance with deadlines. Staff performs drawdowns of CDBG funding through HUD's IDIS online system monthly. Staff will now report the quarterly drawdowns and reconciliation in the Funds Projected/ Funds Drawn spreadsheet to improve monitoring and identification of problems early. This will increase the speed by which Davis spends down its credit line, and reduce gaps in expenditure recording between IDIS and the City's financial management system. In addition, an updated draw-down process, paired with quarterly reconciliation and reporting through the quarterly cash transaction report, will help staff correctly draw entitlement funds. • Anticipated Completion Date: June 30, 2024

View Audit 365226

Finding 575124 (2022-001)

Material Weakness 2022

City of Davis

CA

Reporting Cash Management

Finding Reference Number: SA 2022-001 Accurate Financial Reporting in the Annual PR26 Report and Quarterly PR29 Reports and Failure to File Quarterly PR29 Reports AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Gra...

Finding Reference Number: SA 2022-001 Accurate Financial Reporting in the Annual PR26 Report and Quarterly PR29 Reports and Failure to File Quarterly PR29 Reports AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-15-MC-06-0037, B-16-MC-06-0037, B-17-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037, B-21-MC-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: Since FY 2021, the City has reviewed its organizational structure and processes for management of the CDBG grant program. At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed and implemented a timeline of required actions for the program to ensure compliance with deadlines. • Anticipated Completion Date: June 30, 2024

View Audit 365226

Finding 574631 (2022-002)

Material Weakness 2022

Toledo Lucas County Homelessness Board

OH

Subrecipient Monitoring Cash Management Reporting

Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and ...

Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and training for accurate grant-based reporting. • Accounting software issues related to transition to cloud-based software have been problem solved as possible. • Due to unresolved system limitations, TLCHB will transition to QuickBooks in January 2026, per the recommendation of the independent auditor. STATUS: Implemented bullet 1-4, bullet 5 target January 2025 • Policy to ensure funds are expended within 30 days, with exceptions approved by senior leadership. STATUS: Implemented • Monthly bank reconciliations prepared by Finance Manager and reviewed by leadership, Finance committee. • Additional staff resources allocated to support reconciliation. STATUS: Reconciliations completed; ongoing compliance in place.

View Audit 364896

Finding 574630 (2022-001)

Material Weakness 2022

Toledo Lucas County Homelessness Board

OH

Subrecipient Monitoring Cash Management Reporting

Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and ...

Finding 2022-1 & 2022-2 Control Activities, Information and Communication, Monitoring • Monthly reconciliation of all financial reports within the accounting system. • Dual review by Operations Manager and Board Treasurer at monthly finance committee meetings. • Use of accounting software tools and training for accurate grant-based reporting. • Accounting software issues related to transition to cloud-based software have been problem solved as possible. • Due to unresolved system limitations, TLCHB will transition to QuickBooks in January 2026, per the recommendation of the independent auditor. STATUS: Implemented bullet 1-4, bullet 5 target January 2025 • Policy to ensure funds are expended within 30 days, with exceptions approved by senior leadership. STATUS: Implemented • Monthly bank reconciliations prepared by Finance Manager and reviewed by leadership, Finance committee. • Additional staff resources allocated to support reconciliation. STATUS: Reconciliations completed; ongoing compliance in place.

View Audit 364896

Finding 574259 (2022-013)

Material Weakness 2022

South Central Medical and Resource Center, Inc.

OK

Cash Management § 200.305

Corrective Actions Taken:

View Audit 364764

Finding 574259 (2022-013)

Material Weakness 2022

South Central Medical and Resource Center, Inc.

OK

Cash Management § 200.305

1. SCMRC revised its federal drawdown procedures in 2024 to require documented review and approval of all expenditures before submitting any drawdown request.

View Audit 364764

Finding 574259 (2022-013)

Material Weakness 2022

South Central Medical and Resource Center, Inc.

OK

Cash Management § 200.305

2. A Draw Down Request Workbook is now prepared by the Controller and reviewed against supporting documentation, including invoices, timecards, and purchase records.

View Audit 364764

Finding 574259 (2022-013)

Material Weakness 2022

South Central Medical and Resource Center, Inc.

OK

Cash Management § 200.305

3. The CEO reviews and signs off on each Draw Down Request prior to submission.

View Audit 364764

Finding 574259 (2022-013)

Material Weakness 2022

South Central Medical and Resource Center, Inc.

OK

Cash Management § 200.305

4. Completed Draw Down Request Workbooks are submitted to HRSA for prior approval and retained for audit purposes.

View Audit 364764

Corrective Action Plans

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