Corrective Action Plans

Finding 1171213 (2023-041)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Internal Control / Segregation of Duties § 200.303

VIDOL concurs with the auditor’s findings and recommendations. An electronic record-keeping system for claims files is expected to be launched before the end of FY 2026, enhancing record retention. VIDOL is reviewing its record retention policy and procedures and will provide training to staff on pr...

VIDOL concurs with the auditor’s findings and recommendations. An electronic record-keeping system for claims files is expected to be launched before the end of FY 2026, enhancing record retention. VIDOL is reviewing its record retention policy and procedures and will provide training to staff on proper maintenance and retention of complete program files. VIDOL staff will collaborate with USDOL for technical assistance and data validation to ensure eligibility and record maintenance.

View Audit 384576

Finding 1171188 (2023-027)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.317

The Department of Health concurs with the Auditor’s findings and recommendations. To ensure that the WIC program is included in all processes and receive all documents and correspondence relating to WIC Special Funding as a secondary oversight of the transactions.

View Audit 384576

Finding 1171187 (2023-026)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

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

DOH revised drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted internally or externally.

View Audit 384576

Finding 1171185 (2023-024)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

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

The Department of Health concurs with the auditor’s findings and recommendations. To address this, DOH revised drawdown Standard Operating Procedures (SOPs) for Fiscal Year 2025 to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at c...

The Department of Health concurs with the auditor’s findings and recommendations. To address this, DOH revised drawdown Standard Operating Procedures (SOPs) for Fiscal Year 2025 to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at certification level of certification. DOH have also incorporated this updated procedure into Federal Grants update trainings and made it accessible to all staff on Business Process Improvement SharePoint site.

View Audit 384576

Finding 1171178 (2023-021)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Equipment & Real Property Management Internal Control / Segregation of Duties § 200.303

The Program has drafted a Standard Operating Procedures and Procedures (SOPP) document to outline the EBT Reconciliation process, once the internal review is completed, it will be submitted to the cognizant agency for approval. Additionally, onboarding a Director of Support Services will provide the...

The Program has drafted a Standard Operating Procedures and Procedures (SOPP) document to outline the EBT Reconciliation process, once the internal review is completed, it will be submitted to the cognizant agency for approval. Additionally, onboarding a Director of Support Services will provide the required compliance and oversight for the EBT card security.

View Audit 384576

Finding 1171005 (2023-003)

Material Weakness 2023

Nation's Finest and Subsidiaries

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.303

FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...

FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months

View Audit 384402

Finding 1170992 (2023-004)

Material Weakness 2023

Fusion Parterships, Inc.

MD

Internal Control / Segregation of Duties

Although Fusion reviews all backup submitted to funders for reimbursement, where our process has fallen short is in the corrections to the finance reports internally to match what is submitted in real time. In 2024 Fusion added additional staff review to invoice submission and financial reports. Thi...

Although Fusion reviews all backup submitted to funders for reimbursement, where our process has fallen short is in the corrections to the finance reports internally to match what is submitted in real time. In 2024 Fusion added additional staff review to invoice submission and financial reports. This will be fully corrected with the new finance system going online in Q1 of 2025 and additional process added by our AR staff reviewing expenses when invoices are submitted to ensure accuracy.

View Audit 384386

Finding 1170989 (2023-002)

Material Weakness 2023

Fusion Parterships, Inc.

MD

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will ...

Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will further streamline this process.

View Audit 384386

Finding 1170987 (2023-001)

Material Weakness 2023

Fusion Parterships, Inc.

MD

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Significant Deficiency

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system...

We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses. Additional Partner Engagement Coordinator review of requests and backup documentation has been implemented for weekly approval of disbursements.

View Audit 384386

Finding 1170910 (2023-001)

Material Weakness 2023

Grand Island Regional Medical Center

NE

HUD Housing Programs Reporting Significant Deficiency

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 2...

Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 27, 2025. The Medical Center has implemented a tracking procedure for all grants that includes due dates for required reporting. The Controller maintains a list of compliance requirements for each grant which is reviewed by the Chief Financial Officer. Additionally, the primary contact information for grants is updated upon any changes in personnel to ensure communications are routed to the appropriate individual for follow-up.

View Audit 384219

Finding 1170814 (2023-004)

Material Weakness 2023

Pontotoc County Mississippi

MS

Reporting Internal Control / Segregation of Duties § 200.329

Corrective Action Planned: We will ensure the submission of the reports remian timely and general ledgers from the subject fiscal years are used in preparing the reports. The County will ensure that informaiton garnered from the general ledgers coincide and accurately match future reports before sub...

Corrective Action Planned: We will ensure the submission of the reports remian timely and general ledgers from the subject fiscal years are used in preparing the reports. The County will ensure that informaiton garnered from the general ledgers coincide and accurately match future reports before submission. Anticipated Completions Date: April 1, 2024. Name of person responsible for corrective action: Ricky Ferguson, Chancery Clerk.

View Audit 384080

Finding 1170738 (2023-009)

Material Weakness 2023

Hope the Mission

CA

Reporting Internal Control / Segregation of Duties § 200.510

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Managem...

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.

View Audit 383905

Finding 1170736 (2023-007)

Material Weakness 2023

Hope the Mission

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken sign...

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken significant steps to strengthen accounting procedures and internal controls, reinforce our invoice approval policies, and ensure all expenditures charged to Federal awards are properly reviewed and authorized prior to processing. We have enhanced our Accounts Payable workflow by implementing standardized process approval requirements, added additional leadership staffing and oversight within the Finance and Accounting team and provided targeted training to all personnel involved in invoice processing to ensure understanding of Federal cost principles and documentation standards. These corrective actions have improved our control environment since the audit period, and management is committed to continuing to develop and maintain strong financial controls and to prevent recurrence of this issue.

View Audit 383905

Finding 1170637 (2023-008)

Material Weakness 2023

City of Adelanto

CA

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.334

Recommendation: We recommend the City enhance its internal control by implementing policies and procedures to track wage rate requirements compliance, and ensure that all certified payrolls and supporting wage-rate documentation are retained. Views of Responsible Officials: Management concurs with t...

Recommendation: We recommend the City enhance its internal control by implementing policies and procedures to track wage rate requirements compliance, and ensure that all certified payrolls and supporting wage-rate documentation are retained. Views of Responsible Officials: Management concurs with the finding. The City of Adelanto experienced higher than expected staff turnover in the finance department during the timeframe noted in this audit, which caused a backlog in audit preparation and submission, along with certain financial controls implementation interruption. At the time of this audit publishing, Management believes that implementation of such procedures is in compliance with the noted recommendation. Persons Responsible for Corrective Action: City Finance Staff (various) City Department Heads applying for grant funding (various) City Project Managers (various) Anticipated Completion Date for Corrective Action: Corrective action has been immediately implemented in response to the auditors’ recommendation. As financial reporting is still in the process of becoming current, the City anticipates finding to be removed in future fiscal years.

View Audit 383868

Finding 1170506 (2023-006)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Internal Control / Segregation of Duties Reporting Significant Deficiency § 200.303

SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.

View Audit 383712

Finding 1170503 (2023-003)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.

View Audit 383712

Finding 1170502 (2023-002)

Material Weakness 2023

Survivor Advocacy Outreach Program

OH

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

SAOP shall implement a policy to secure approvals for charges related to the federal program.

View Audit 383712

Finding 1170351 (2023-001)

Material Weakness 2023

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 383444

Finding 1169874 (2023-003)

Material Weakness 2023

City of Reedsburg

WI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do n...

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor

View Audit 383031

Finding 1169787 (2023-006)

Material Weakness 2023

Temenos Community Development Corporation

TX

Special Tests & Provisions HUD Housing Programs Significant Deficiency § 200.303

2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...

2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025

View Audit 382882

Finding 1169782 (2023-005)

Material Weakness 2023

Temenos Community Development Corporation

TX

Subrecipient Monitoring Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...

2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025

View Audit 382882

Finding 1169562 (2023-004)

Material Weakness 2023

LUTI R-VI SCHOOL DISTRICT

MO

Subrecipient Monitoring Internal Control / Segregation of Duties

Internal Control over Major Federal Program Compliance Program: Education Stabilization Fund (CFDA 84.425) Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to require prevailing ...

Internal Control over Major Federal Program Compliance Program: Education Stabilization Fund (CFDA 84.425) Condition: Lack of policies and procedures for verifying and monitoring Wage Rate Requirements. Material Weakness Corrective Action Plan: The District will adopt policies to require prevailing wage payments for contractor employees working an federally funded projects. The District will adopt policies and implement procedures requiring contractors on federally funded projects provide certified payroll reports to the District to ensure compliance with Wage Rate Requirements. The District will implement verification procedures to ensure contractor compliance with prevailing wage payments to employees. Planned Completion Date: March 20, 2024 Responsible Contact Perosn: Kathalee Cole, Superintendent (417) 273-4274

View Audit 382546

Finding 1169431 (2023-002)

Material Weakness 2023

Comanche County Medical Center

TX

Cash Management Reporting Internal Control / Segregation of Duties

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. 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 ...

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. 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 382372

Finding 1169213 (2023-001)

Material Weakness 2023

SANTA CRUZ COUNTY VETERANS MEMORIAL BUILDING BOARD OF TRUSTEES

CA

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking § 200.303 § 200.318 § 200.327

Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.

View Audit 382113

Finding 1169158 (2023-002)

Material Weakness 2023

City of Tahlequah

OK

Reporting Internal Control / Segregation of Duties

Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s...

Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding SEFA preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.

View Audit 382015

Corrective Action Plans

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