Corrective Action Plans

Finding 571578 (2024-005)

Significant Deficiency 2024

Housing Authority of the City of Seattle

WA

HUD Housing Programs Subrecipient Monitoring Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review the controls in place to ensure that the inspections team can complete the reinspections in a timely manner and are knowledgeable of all internal procedures in place over...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review the controls in place to ensure that the inspections team can complete the reinspections in a timely manner and are knowledgeable of all internal procedures in place over inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCV will complete a comprehensive redesign of its inspection scheduling process in 2025 and provide training to the Inspections Coordinators. Additional reports have been developed to identify past due inspections, and, in addition to the Inspections Manager, the Compliance Team will closely monitor them in addition to ensure any outstanding inspections are cured.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Preventive actions will be ongoing as part of the regular compliance and quality management process. The Management Team has been required to clear all work backlogs by the end of FY2025.

View Audit 362508

Finding 571567 (2024-004)

Significant Deficiency 2024

Housing Authority of the City of Seattle

WA

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review the controls in place to ensure that no tenants are overlooked, even when the original case manager is no longer an employee of the Authority. Explanation of disagreemen...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority review the controls in place to ensure that no tenants are overlooked, even when the original case manager is no longer an employee of the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCV has developed new software process workflows that automatically incorporate completion of certification checklists. Work backlogs created by staff turnover are being addressed. The Management Team has a created a plan of action with a timeline to clear all backlogs by the end of 2026. The team meets on a weekly basis to discuss progress. Additional oversight of termination processes will be provided by Compliance Team review of payment holds and $0 HAP reports.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Preventive actions will be ongoing as part of the regular compliance and quality management process. The Management Team has been required to clear all work backlogs by the end of FY2025.

View Audit 362508 Questioned Costs: $1

Finding 571556 (2024-003)

Significant Deficiency 2024

Housing Authority of the City of Seattle

WA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management designate one person to oversee the rent reasonableness determination for new tenants and contract rent changes to ensure rent reasonableness is completed properly and accurately flows ...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management designate one person to oversee the rent reasonableness determination for new tenants and contract rent changes to ensure rent reasonableness is completed properly and accurately flows to the HAP contract and HUD-50058 form. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCV will conduct refresher trainings on rent reasonable requirements for all staff that conduct rent reasonable certifications throughout the year. In addition to the existing monthly audit/compliance reviews of certifications that include rent reasonable determinations, managers will review a sample of rent reasonable certifications by staff that the Compliance Team identifies as needing additional support.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Trainings provided throughout the year along with a monthly audit being conducted by the manager of a sample of rent reasonableness certifications.

View Audit 362508 Questioned Costs: $1

Finding 571545 (2024-002)

Material Weakness 2024

Housing Authority of the City of Seattle

WA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are i...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend management designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: NSPIRE enforcement has been an existing area of focus for the HCV Department during the past year. The one of the primary root causes of the issues identified was leadership of the inspections team that changed in 2023, and direct oversight of the inspection processes was not sufficient and/or effective. The agency recently hired a new Inspections Manager, who is fully trained and is experienced in property management. A working group including the recently hired Inspections Manager, Compliance Manager, and Deputy Director of HCV currently meets weekly to (utilization the NSPIRE compliance reports) review NSPIRE non-compliance processing. There are dashboard reports that are utilized to detect and address units that are in non-compliance with the NSPIRE standards.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: June 2025

View Audit 362508 Questioned Costs: $1

Finding 571543 (2024-007)

Material Weakness 2024

County of Floyd

IA

Internal Control / Segregation of Duties

We will review procedures and plan to make the necessary changes to improve internal control.

View Audit 362505

Finding 571541 (2024-005)

Material Weakness 2024

Tca Health, Inc.

IL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303 § 200.305

Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be do...

Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented with supporting documentation retained for the revised internal control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA will have a Grant/Staff Account or designee prepare documentation for the drawdowns. The CEO or designee will approve drawdown documents. CFO/Controller or designee will process the drawdown and take a screenshot when completed. All approvals will be shown on the excel sheet with the drawdown information. Name(s) of the contact person(s) responsible for corrective action: Jeremy Runde, Controller Planned completion date for corrective action plan: June 2025

View Audit 362500

Finding 571538 (2024-002)

Material Weakness 2024

Tca Health, Inc.

IL

Eligibility Material Weakness Internal Control / Segregation of Duties

Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient v...

Recommendation: Management should continue to provide training and education to front desk staff related to the process for collecting family size and income information, along with inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information has been obtained in accordance with TCA’s policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health has addressed the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff were trained in the approved sliding fee scale policy and its requirements. Worked with third-party billing company, and Athena to roll back the EMR update which contributed to ineffective application of the sliding fee in November 2023. TCA hired a full-time Patient Services Manager in 2024 to support ongoing staff training, quality assurance monitoring, and implementation of the updated EMR and registration workflows. Staff have become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. Additionally, TCA began to undergo internal audits of records ensuring that proper documentation is maintained and a patient service manager, utilizing testing template provided by the organization’s auditor. Name(s) of the contact person(s) responsible for corrective action: Samantha Oliver Mitchell, Chief Operating Officer Planned completion date for corrective action plan: June 2025

View Audit 362500

Finding 571521 (2024-004)

Significant Deficiency 2024

Housing & Redevelopment Authority of Douglas County

MN

HUD Housing Programs Internal Control / Segregation of Duties Significant Deficiency

Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has determined they will contract with a local vendor to perform the annual utility rate review going forward. The Authority will perform a review of the report they receive. Planned Completion Date for CAP D...

Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has determined they will contract with a local vendor to perform the annual utility rate review going forward. The Authority will perform a review of the report they receive. Planned Completion Date for CAP December 31, 2025

View Audit 362477

Finding 571515 (2024-002)

Significant Deficiency 2024

Housing & Redevelopment Authority of Douglas County

MN

HUD Housing Programs Eligibility Significant Deficiency

Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has conducted appropriate training for all staff to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2025

View Audit 362477

Finding 571507 (2024-003)

Significant Deficiency 2024

McNary Elementary School District No. 23

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties

Th<· District will ensure all supporting documentation is prepared and ready for auditors. In addition, audit services will be procured with sufficient time to submit the single audit by the required timeline.

View Audit 362459

Finding 571506 (2024-002)

Material Weakness 2024

McNary Elementary School District No. 23

AZ

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.333

The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.

View Audit 362459

Finding 571498 (2024-001)

Material Weakness 2024

City of Loveland

CO

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy...

Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy, and timeliness of submission. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 6/30/2025

View Audit 362454

Finding 571493 (2024-003)

Material Weakness 2024

Lyons Fire District

NY

Internal Control / Segregation of Duties Reporting

Segregation of Duties Year ended December 31, 2024 Auditors’ Recommendation: The Fire District should continue to obtain involvement from the Board of Fire Commissioners in reviewing monthly financial reports and approving expenditures. In addition, the Fire District should consider having a Board m...

Segregation of Duties Year ended December 31, 2024 Auditors’ Recommendation: The Fire District should continue to obtain involvement from the Board of Fire Commissioners in reviewing monthly financial reports and approving expenditures. In addition, the Fire District should consider having a Board member prepare or review bank reconciliations for each of its bank accounts. Fire District Response: Meghan Nagel, Treasurer, and Brian Engels, Board chairman, understand the importance of having strong segregation of duties and will attempt to separate certain responsibilities as outline above for the year ending December 31, 2025, but does prove difficult in a small district with minimal employees. The Fire District will continue to have the Board review monthly reports and approve expenditures. Further, the Fire District will continue to print the operating account reconciliation and will have that reviewed by a board member. The Fire District will start printing the reconciliation for all other accounts for them to be reviewed by a board member, as well continuing to print each bank statement to be reviewed.

View Audit 362438

Finding 571488 (2024-001)

Material Weakness 2024

Deschutes Land Trust

OR

Reporting Internal Control / Segregation of Duties Material Weakness § 200.303

WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there i...

WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: Ensure the Stewardship Director reviews and signs the SF-425. Action Plan: Amend existing policies associated with federal grants, to require the Program Director responsible for overseeing projects using federal funds to sign any required and submitted financial reports. Name(s) of the contact people responsible for correction action: Michael Rubovits Plan completion date for corrective action plan: 8/31/2025

View Audit 362417

Finding 571487 (2024-004)

Significant Deficiency 2024

Academy of Accelerated Learning, INC

TX

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

Managements Response: Academy of Accelerated Learning, Inc. leadership will develop, along with new financial management a plan for improvement to be presented to the Board which includes a review of its internal control procedures over financial reporting to ensure controls are in place to designat...

Managements Response: Academy of Accelerated Learning, Inc. leadership will develop, along with new financial management a plan for improvement to be presented to the Board which includes a review of its internal control procedures over financial reporting to ensure controls are in place to designate the preparer and approver, to properly and timely record all accounts in accordance with generally accepted accounting principles. Academy of Accelerated Learning, Inc. will establish timelines and training for the expense approval process. Leadership and the new financial management will designate staff to align with a segregation of duties and hold staff accountable. Timeline and Responsible Position: By August 31, 2026. Board of Directors, Superintendent, and Chief Financial Officer.

View Audit 362410

Finding 571482 (2024-003)

Significant Deficiency 2024

Eastern Plains Community Action Agency, Inc.

NM

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy ...

We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy in place to correct this finding that was approved by the board on August 9, 2024.

View Audit 362404

Finding 571464 (2024-006)

Significant Deficiency 2024

City and County of Denver

CO

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recom...

Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the City establish and implement a formal process to consistently retain documentation of FFATA report submission dates, as well as evidence of the review and approval of each report submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Denver’s Department of Economic Development and Opportunity (DEDO) will establish a formal approval process to establish and document submission dates of all FFATA filings going forward. While the Federal Government does not provide any timestamps of initial submission for FFATA filings, nor require approval for FFATA submissions, DEDO will begin providing written and dated approvals of when FFATA reporting is taking place. We will put together a formal process that will provide dates to show review/approval of FFATA filings to meet our external auditor’s request, despite the Federal Government not requiring it. DEDO is able to provide a documented historical consistency of maintaining effective internal controls over this Federal award, and will begin including FFATA filings in the documentation that is already maintained showing timely submission of reporting to the Federal Government. Name(s) of the contact person(s) responsible for corrective action: Fanta Harkiso & Derek Cary Planned completion date for corrective action plan: August 31, 2025

View Audit 362374

Finding 571439 (2024-001)

Material Weakness 2024

Hancock County, Illinois

IL

Subrecipient Monitoring Internal Control / Segregation of Duties

Corrective Action Plan: The County Board will continue to review all claims provided to them. Anticipated Completion Date: The County is not in a financial position to hire additional employees. The increased monitoring has already begun. Responsible Parties: Mark Menn, County Board Chairman. 500 M...

Corrective Action Plan: The County Board will continue to review all claims provided to them. Anticipated Completion Date: The County is not in a financial position to hire additional employees. The increased monitoring has already begun. Responsible Parties: Mark Menn, County Board Chairman. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3986; Kris Pilkington, County Treasurer. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3986; Holly Wilde-Tillman, County Clerk. 500 Main Street, P.O. Box 248 Carthage, Illinois 62321. (217) 357-3911

View Audit 362373

Finding 571438 (2024-004)

Material Weakness 2024

Town of Paoli

IN

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Descrip...

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately

View Audit 362372

Finding 571435 (2024-002)

Material Weakness 2024

Hope Shines Bright Holding Company, Inc.

NV

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Cash Management § 200.62

2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and ...

2004-002: Controls over Allowable Costs, etc. St. Jude’s Ranch for Children (the parent entity of HSB Holding Company) acknowledges that weaknesses in the financial oversight process contributed to this finding. Specifically, limited knowledge of Generally Accepted Accounting Principles (GAAP) and federal cost principles by key financial personnel led to misclassification of costs and errors in reimbursement requests in a new type of grant unfamiliar to the accounting team. In response, the organization is restructuring its finance department to ensure that individuals with appropriate qualifications and experience in nonprofit GAAP and federal grant compliance are responsible for reviewing accounting records and reimbursement requests. This includes a new Chief Financial Officer with demonstrated experience in federal grant accounting and compliance and a dedicated grants manager to prepare all reimbursement submissions under the oversight of the CFO.

View Audit 362369

Finding 571432 (2024-001)

Material Weakness 2024

City of Cleveland

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The Department of Community Development is actively developing a formalized process to ensure FFATA compliance for all first-tier subawards exceeding $30,000. The following actions are currently underway and are anticipated to be fully implementation on July 1, 2025: Assignment of Responsibility – ...

The Department of Community Development is actively developing a formalized process to ensure FFATA compliance for all first-tier subawards exceeding $30,000. The following actions are currently underway and are anticipated to be fully implementation on July 1, 2025: Assignment of Responsibility – A designated staff member within the Fiscal Operations unit is being identified to assume primary responsibility for FFATA reporting and compliance trackingPolicy and Procedure Development – Comprehensive written procedures are being drafted to support consistent FFATA complianceTraining – Plans are in place to provide appropriate staff with the targeted training on FFATA requirements and FSRS system functionality to ensure readiness and compliance.Monitoring and Internal Controls – The Department is designing a compliance calendar and supervisory review process to track reporting deadlines and ensure adequate oversight prior to FRSR submissionSubrecipient Notification – Beginning in July 2025 program cycle, all subrecipients receiving federal awards exceeding $30,000 will be notified in their funding award letters of these additional FFATA related reporting and monitoring requirements.Review of Prior-Year Activity – The Department is reviewing subawards made during the previous reporting to assess the feasibility of retroactive reporting in consultation with the United States Department of Housing and Urban Development guidance.

View Audit 362367

Finding 571428 (2024-002)

Material Weakness 2024

Albia Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will continue to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We have made changes internally that shift responsibilities between the Business Manage and Office Manager which provides an additional person having responsibilities...

The District will continue to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We have made changes internally that shift responsibilities between the Business Manage and Office Manager which provides an additional person having responsibilities with investments, cash, and the overall financial reporting.

View Audit 362355

Finding 571397 (2024-001)

Material Weakness 2024

Jefferson County Iowa

IA

Internal Control / Segregation of Duties

Segregation of Duties Name of contact person: Christy Conner, County Auditor Corrective Action: The duties will be separated as much as possible and alternative controls will be considered to compensate for lack of separation. Proposed Completion Date: Ongoing.

View Audit 362348

Finding 571395 (2024-002)

Material Weakness 2024

Windham Exempted Village School District

OH

Equipment & Real Property Management Internal Control / Segregation of Duties § 200.313

The District will maintain property records in accordance with District Policy & Uniform Guidance and ensure that equipment and/or property acquired with federal funds will be inventoried and reconciled within two preceding years of acquisition.

View Audit 362333

Finding 571391 (2024-001)

Material Weakness 2024

St. Vincent General Hospital District

CO

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.

View Audit 362330

Corrective Action Plans

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