Corrective Action Plans

Finding 555497 (2023-004)

Significant Deficiency 2023

Sacramento Housing and Revelopment Agency

CA

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Recommendation: We recommend that the Agency reviews the controls in place to ensure that payroll transactions are charged to the correct program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recu...

Recommendation: We recommend that the Agency reviews the controls in place to ensure that payroll transactions are charged to the correct program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we began implementing a corrective action plan. The Agency hired a Payroll Analyst in January 2025, who will be tasked with reviewing payroll transactions and reports on a monthly/quarterly basis and ensuring that payroll charges are reflected in the correct program. Name(s) of the contact person(s) responsible for corrective action: Irene De Jong, DIRECTOR OF FINANCE Planned completion date for corrective action plan: December 31, 2025

View Audit 354004 Questioned Costs: $1

Finding 555494 (2023-003)

Significant Deficiency 2023

Sacramento Housing and Revelopment Agency

CA

Special Tests & Provisions HUD Housing Programs Internal Control / Segregation of Duties

Recommendation: We recommend management should 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. Expla...

Recommendation: We recommend management should 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: To prevent a recurrence of the issue, we began implementing a comprehensive correction plan and made key adjustments to our Quality Controll (QC) inspection process. Beginning in mid-2023, we now select a higher number of files for QC inspections to accommodate any that may be inconclusive or result in no-shows while still meeting the required standard of passed QC inspections. Additionally, we have changed our selection criteria from a 90-day pool to a 30-day pool to ensure timely scheduling and compliance, in case a re-inspection is necessary. These changes were also reiterated to Nan McKay Associates, SHRA’s consultant assisting with the housing inspection process. Name(s) of the contact person(s) responsible for corrective action: MaryLiz Paulson, Director, Housing Choice Vouchers Planned completion date for corrective action plan: December 31, 2025

View Audit 354004

Finding 555491 (2023-002)

Material Weakness 2023

Sacramento Housing and Revelopment Agency

CA

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Recommendation: We recommend that management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have...

Recommendation: We recommend that management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we have implemented a comprehensive corrective action plan. Specifically, we developed a comprehensive Standard Operating Procedure (SOP) for file reviews related to recertification. Additionally, the HCV Operations Unit is reviewing a sample of completed recertifications monthly to ensure compliance. Detailed supporting documentation can be found at the following link: https://sachousing.box.com/s/fiqoaoddr7ae6nydf63f1mhwfnrpzfr6 Name(s) of the contact person(s) responsible for corrective action: MaryLiz Paulson, Director, Housing Choice Vouchers Planned completion date for corrective action plan:: December 31, 2025

View Audit 354004 Questioned Costs: $1

Finding 555278 (2023-005)

Material Weakness 2023

Cicoa Aging & In-Home Solutions

IN

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303

Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time th...

Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time that adequate staffing for review is in place, a member of management or their designee will develop and maintain a tickler list of all reporting requirements and due dates to ensure all reports are submitted timely.

View Audit 353908

Finding 555266 (2023-004)

Material Weakness 2023

Cicoa Aging & In-Home Solutions

IN

Internal Control / Segregation of Duties Cash Management § 200.303

Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time th...

Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Leadership is currently considering options for adequate oversight and review. Until such time that adequate staffing for review is in place, a member of management or their designee will review claims.

View Audit 353908

Finding 555252 (2023-005)

Significant Deficiency 2023

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 353876

Finding 555237 (2023-001)

Material Weakness 2023

Municipality of Lennox

SD

Internal Control / Segregation of Duties Material Weakness

A material weakness in internal controls was noted due to a lack of proper segregation of duties for revenues. This affects the compliance requirement for Coronavirus State and Local Fiscal Recovery Funds, ALN No. 21.027. Corrective Action: The City of Lennox's Mayor, Danny Fergen, is the contact...

A material weakness in internal controls was noted due to a lack of proper segregation of duties for revenues. This affects the compliance requirement for Coronavirus State and Local Fiscal Recovery Funds, ALN No. 21.027. Corrective Action: The City of Lennox's Mayor, Danny Fergen, is the contact person responsible for the corrective action plan of this finding. Because of the size of the City of Lennox, the municipality cannot support hiring additional staff that would be sufficient to support the internal controles neceessary to properly segregate duties. The Mayor, City Council, and Finance employees are aware of this challenge, and have put in place controls that minimize risk.

View Audit 353866

Finding 555233 (2023-003)

None 2023

Boys and Girls Club of Lake County

IL

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties

Condition: During the audit it was noted that, in most of the instances, employee timecards were missing. Plan: The Club will review their monitoring procedures to ensure consistent retention of employee timecards. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Co...

Condition: During the audit it was noted that, in most of the instances, employee timecards were missing. Plan: The Club will review their monitoring procedures to ensure consistent retention of employee timecards. Anticipated Date of Completion: As soon as possible – before FY25 year end Name of Contact Person: Germain Castellanos, CEO Management Response: Since the audit, we have reviewed our monitoring procedures to ensure consistent approval of employees timecards.

View Audit 353845

Finding 555180 (2023-002)

Significant Deficiency 2023

Porchlight, Inc.

WI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure...

We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure that all relevant documents and information required for the reports are readily accessible and properly maintained, minimizing delays caused by searching for necessary materials. We will institute a schedule for regular reviews and monitoring of the reporting process. This will involve conducting periodic assessments to identify any bottlenecks or potential issues that could lead to delays, allowing for proactive intervention and resolution. By implementing these measures, we aim to mitigate the risk of late filing of the audit report, thereby enhancing compliance with regulatory requirements and ensuring timely and accurate reporting.

View Audit 353787

Finding 555151 (2023-008)

Significant Deficiency 2023

Samu Foundation

DC

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials: Based on this audit finding, SAMU agreed addressing the following: 1. Implement a formal review and approval process for program reports, including documentation of reviewer's name and date. 2. Establish a system to retain internal documentation of report submission d...

Views of Responsible Officials: Based on this audit finding, SAMU agreed addressing the following: 1. Implement a formal review and approval process for program reports, including documentation of reviewer's name and date. 2. Establish a system to retain internal documentation of report submission dates. 3. Develop a reporting calendar with internal deadlines for report preparation and review. 4. Designate specific individuals responsible for report preparation, review, and submission.

View Audit 353757

Finding 555110 (2023-001)

Material Weakness 2023

Crosspurpose

CO

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.4

Effective October 1, 2023, management implemented extensive accounting and documentation controls to ensure full accounting and reporting compliance on direct costs incurred for all federal grants and expenditures. These controls are reviewed and monitored for compliance by management on a periodic ...

Effective October 1, 2023, management implemented extensive accounting and documentation controls to ensure full accounting and reporting compliance on direct costs incurred for all federal grants and expenditures. These controls are reviewed and monitored for compliance by management on a periodic basis during the year.

View Audit 353705 Questioned Costs: $1

Finding 554894 (2023-002)

Material Weakness 2023

Lincoln Hall

NY

Internal Control / Segregation of Duties Material Weakness Reporting

Finding Number: 2023-002 Closing Process – (Material Weakness) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, the quantity of entries to close the books, the reconciliation of the beginning trial balance to the prior year aud...

Finding Number: 2023-002 Closing Process – (Material Weakness) Planned Corrective Action: The auditors noted issues related to the timeliness of the financial statement close process, the quantity of entries to close the books, the reconciliation of the beginning trial balance to the prior year audited trial balance, and a lack of segregation of duties which led to journal entries being prepared, reviewed and posted by the same person in the general ledger system. The issues noted were largely the result of significant turnover within the Finance Department, including the departure of the former head of the department without a proper transfer of institutional knowledge to remaining staff or incoming leadership. Since that time, oversight has improved considerably, and key processes have been reviewed, updated, and formally documented. While the current size of the Finance Team necessitates that the same individual generally enters and posts journal entries, we have implemented compensating controls that we believe are appropriate given the assessed levels of risk and materiality. These controls include role-specific responsibilities for journal entries and reconciliations. For example, with respect to cash activity, different team members handle cash receipts, disbursements, and inter-account transfers. A fourth team member is responsible for preparing the monthly bank reconciliations, which are then formally reviewed and signed off by Fiscal Department management, including the CFO. Management remains committed to strengthening internal controls, maintaining adequate segregation of duties to the extent practicable, and continuing to enhance the overall financial close and reporting process. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: April 30, 2025

View Audit 353459

Finding 554521 (2023-005)

Significant Deficiency 2023

Mills County

IA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The County will ensure future reports are completed on time.

View Audit 353211

Finding 554485 (2023-002)

Material Weakness 2023

Holbrook Housing Authority

MA

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2023-002 - Reporting Auditee’s Response and Planned Corrective Action The Authority is now under the management of the Quincy Housing Authority and all controls and processes have been updated to account for the needs of the Holbrook Housing Authority, including internal controls over financial re...

2023-002 - Reporting Auditee’s Response and Planned Corrective Action The Authority is now under the management of the Quincy Housing Authority and all controls and processes have been updated to account for the needs of the Holbrook Housing Authority, including internal controls over financial reporting, documentation retention, and timeliness of reporting. Planned Implementation Date of Corrective Action: June 30, 2024 Person Responsible for Corrective Action: James Marathas, Executive Director

View Audit 353119

Finding 554473 (2023-003)

Significant Deficiency 2023

Meals on Wheels of Middle Georgia, Inc.

GA

Internal Control / Segregation of Duties Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Actions: See Comment 2023-001 and 002. Date to be implemented: See Comment 2023-001 and 002. Persons responsible: See Comment 2023-001 and 002

View Audit 353107

Finding 554444 (2023-007)

Significant Deficiency 2023

Leech Lake Tribal College

AZ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

View Audit 353088

Finding 554432 (2023-005)

Material Weakness 2023

Leech Lake Tribal College

AZ

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

The Department has hired a new audit firm that specializes in the audits of Tribes. Our new audit firm has demonstrated a commitment to allocating the necessary resources to complete our audits in a timely manner.

View Audit 353088

Finding 554426 (2023-004)

Material Weakness 2023

Leech Lake Tribal College

AZ

Internal Control / Segregation of Duties Material Weakness

The College is in the process of establishing journal entry controls including an independent review and approval process for all entries and ensuring sufficient documentation is maintained for each entry.

View Audit 353088

Finding 554420 (2023-003)

Material Weakness 2023

Leech Lake Tribal College

AZ

Internal Control / Segregation of Duties Material Weakness

The College has spent a significant amount of time in FY 2025 evaluating their IT controls and policies and procedures. New internal controls are expected to be implemented to address these findings.

View Audit 353088

Finding 554398 (2023-002)

Material Weakness 2023

Island County Economic Development Council

WA

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

Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding ...

Material Weakness in Compliance and Internal Control over Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence is retained by ICEDC as proof of oversight of expenditure of federal funds. Additionally, we recommend adding a review and approval process for the ED’s timesheets. There is no disagreement with the audit finding. Action taken in response to finding: ICEDC appreciates CLA’s recommendation to enhance processes concerning the retention of documentary evidence of approvals and importance of maintaining strong oversight of expenditures, especially when handling federal funds. ICEDC will place greater emphasis on obtaining and retaining documentation of approvals related to the expenditure of funds. This documentation will serve as proof of oversight, ensuring compliance with federal regulations and enhancing transparency in fund management. A formal review and approval process will be established for the Executive Director's (ED’s) timesheets. This process will involve periodic reviews by a designated authority and documentation will be retained to maintain a clear audit trail. Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025

View Audit 353072 Questioned Costs: $1

Finding 554367 (2023-001)

Material Weakness 2023

Housing Authority of the City of Conway

AR

Internal Control / Segregation of Duties Reporting

Housing Authority of the City of Conway respectfully submits the following corrective action plan for the year ended September 30, 2023. Responsible Official: Catherine Lamberg, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, ...

Housing Authority of the City of Conway respectfully submits the following corrective action plan for the year ended September 30, 2023. Responsible Official: Catherine Lamberg, Executive Director Name and address of independent public accounting firm: Miller & Rose, PA 1309 East Race Searcy, AR 72143 Audit period: Year ended September 30, 2023 Oversight Agency: U.S. Department of Housing and Urban Development The findings from the September 30, 2023, audit are discussed below. The findings are numbered to correspond to the auditing findings disclosed in the Schedule of Findings and Questioned Costs. MATERIAL WEAKNESSES Finding 2023-001 – Material Misclassifications • Criteria: A control deficiency exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions to prevent or detect misstatements of the financial statements on a timely basis. AU-C Section 265 Communication Internal Control Related Matters Identified in an Audit, identifies deficiencies in controls over the period-end financial reporting process, including controls over procedures used to enter transactions and journal entries into the general ledger and to record recurring and nonrecurring adjustments to the financial statements that was not initially identified by the entity’s internal controls even if management subsequently corrects the misstatement. • Condition: Material misclassifications in the financial statements under audit. Multiple accounts were not reconciled on a regular basis. In addition, deposits were not recorded on a timely basis resulting in material errors on the financial data schedule that was submitted to REAC. • Context: Several items were discovered that were misclassified. More specifically, assets, liabilities, revenues and expenses were not able to be verified or reconciled. • Effect: The financial statements of Housing Authority of the City of Conway were not materially correct. • Recommendation: Review procedures for proper classification of expenditures and reconcile accounts on a regular basis. • Planned Corrective Actions: We are working with our accountant to resolve the issue. During the current fiscal year, our accountant was not able to access our financial records on a timely basis which resulted in multiple items not being recorded or reconciled. We anticipate these issues being resolved prior to completion of the next audit.

View Audit 352989

Finding 554356 (2023-005)

Significant Deficiency 2023

Exeter Township School District

PA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Federal Program Education Stabilization Fund - Passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Period 03/13/20 - 09/30/24 COVID-19 - ARP ESSER Learning Loss Set Aside ALN 84...

Federal Program Education Stabilization Fund - Passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Period 03/13/20 - 09/30/24 COVID-19 - ARP ESSER Learning Loss Set Aside ALN 84.425U; Contract #225-21-0141; Grant Period 03/13/20 - 09/30/24 Criteria In accordance with Uniform Guidance Post Federal Award Requirements, the District must establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition The District did not maintain effective internal controls over the Federal awards. Two invoices were coded to the grants that were paid without documented approval. Cause The District did not follow documented internal control procedures which require all disbursements to have an approved purchase order or invoice signed by an administrator. Effect By paying invoices coded to Federal grants without approval, the District is not verifying the allowability of invoices. This increases the risk that unallowable activities and costs can be charged to the Federal grants and go undetected. Questioned Costs None. Context The Education Stabilization Fund grant nonpayroll costs were made up of 23 invoices. We tested three individually significant and five sampled invoices. Of the five sampled invoices, we found that two invoices were paid without approval. However, no discrepancies were identified in the allowability of the invoices. Repeat Finding No. Recommendation We recommend the District follow documented internal control procedures requiring all disbursements have an approved purchase order or signed invoice. This will ensure that invoices coded to Federal grants are reviewed for allowability before they are applied to the grants. Management Response This has been rectified. The district had a vacancy in the Federal Program Coordinator. Either the new Federal program Coordinator or the Business Administrator will approve and initial the invoices prior to payment.

View Audit 352972

Finding 554285 (2023-001)

Significant Deficiency 2023

New Beginning International Ministry Inc.

TN

Reporting Internal Control / Segregation of Duties

Corrective Action: The Organization is working with their financial institution to see if statement closing dates can better align with the reporting period. The Organization will perform the reconciliation if no changes can be made with the bank

View Audit 352876

Finding 554151 (2023-019)

Significant Deficiency 2023

State of California

CA

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.300 § 200.303 § 200.309 § 200.403

The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control...

The CDSS’ Disability Determination Services Division (DDSD) has implemented corrective measures to address inaccuracies in the Modernized Integrated Disability Adjudicative System (MIDAS) and Disability Case Processing System (DCPS) invoice review processes. This includes an internal quality control process to monitor and review additional invoice samples from Branches after they have been processed and reviewed by Branch Program Technicians and Branch Auditors. Additionally, the DDSD Central Support Services Branch implemented a secondary audit process and created a new Auditor role to routinely sample additional Medical Evidence of Record (MER) and Consultative Examination (CE) contracts. Findings are provided to branches to reinforce accuracy and assure compliance. The DDSD, also transitioned from MIDAS to DCPS, which provides more sophisticated fiscal controls. To remediate any inaccuracies, DDSD’s centralized auditor will assess findings and develop an action plan to prevent erroneous invoices. The CDSS ensures that all necessary controls are in place to verify the accuracy and proper documentation of invoices. The CDSS concludes that the sample size of 15 MER cases does not provide sufficient audit evidence that controls are not operating effectively resulting in a calculated $54,398 in potential costs. However, CDSS agrees with the finding and is committed to the control and mitigation of risk related to the audit recommendation. Estimated Implementation Date: Implemented Contact: Bernice Stanfield, Fiscal and Procurement Section Chief Central Support Services Branch Disability Determination Service Division California Department of Social Services

View Audit 352774 Questioned Costs: $1

Finding 554148 (2023-016)

Material Weakness 2023

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch ...

CDPH is addressing the findings of the audit through a combination of outreach and training for internal stakeholders, updated internal policies, and data verification to ensure proper review and approval of the Form CMS-1539. Estimated Implementation Date: April 2025 Contact: Nate Gilmore, Branch Chief Center for Health Care Quality California Department of Public Health

View Audit 352774

Corrective Action Plans

Filters