Corrective Action Plans

Finding 481359 (2023-001)

Material Weakness 2023

CA

Cash Management Material Weakness Reporting

Views of Responsible Officials and Corrective Actions: Community Action of Napa Valley has participated in the season of sharing program for more than 10 years. So far the practice has been to recognize revenue when funding is received and at the end of the year credit any unused funds to deferred r...

Views of Responsible Officials and Corrective Actions: Community Action of Napa Valley has participated in the season of sharing program for more than 10 years. So far the practice has been to recognize revenue when funding is received and at the end of the year credit any unused funds to deferred revenue. Per auditor recommendation, CANV will only record assets and offsetting liabilities, not the expense and revenue of any season of sharing activities.

View Audit 317399

Finding 481324 (2023-003)

Material Weakness 2023

Rural Resources Community Action

WA

Subrecipient Monitoring Material Weakness Reporting

FINDING 2023-003 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Department of Labor Views of responsible officials and planned corrective actions: Management agrees with the assessment and is in the process of implementing corrective action....

FINDING 2023-003 – Reporting; Material Weakness in Internal Control over Compliance and Instance of Material Noncompliance Department of Labor Views of responsible officials and planned corrective actions: Management agrees with the assessment and is in the process of implementing corrective action. The Organization has tightened controls for grant management. Claims are subject to two levels of review before submission. Due dates of reports are closely tracked and supporting documentation is retained. Additionally, the improved controls that have been implemented in the fiscal department help to ensure accurate and timely reporting. Contact Persons: Ryan Berendsen, Chief Operating Officer Delana Kromer, Controller

View Audit 317396

Finding 481321 (2023-001)

Significant Deficiency 2023

Sistercare, INC

SC

HUD Housing Programs Internal Control / Segregation of Duties

Corrective Action: The duties will be segregated as much as possible. We understand that in most cases, the added cost of providing absolute segregation of duties will outweigh the projected benefits of the added internal controls and therefore, may be considered unjustified. Sistercare, Inc. will e...

Corrective Action: The duties will be segregated as much as possible. We understand that in most cases, the added cost of providing absolute segregation of duties will outweigh the projected benefits of the added internal controls and therefore, may be considered unjustified. Sistercare, Inc. will ensure that the Board of Directors will remain involved in the financial affairs of the Organization to provide oversight and independent review functions.

View Audit 317393

Finding 481320 (2023-002)

Significant Deficiency 2023

City of Overland Park, Kansas

KS

Subrecipient Monitoring Reporting Significant Deficiency § 200.514

Personnel Responsibile for Corrective Action: Janice Meier, Manager of Financial Services. Anticipated Completion Date: June 2024.Tracking and reporting ARPA expenditures includes many steps: - Assistant City Manager and Law approve projects submitted for use of ARPA funds. - Projects approved for ...

Personnel Responsibile for Corrective Action: Janice Meier, Manager of Financial Services. Anticipated Completion Date: June 2024.Tracking and reporting ARPA expenditures includes many steps: - Assistant City Manager and Law approve projects submitted for use of ARPA funds. - Projects approved for full or partial funding from ARPA funds are approved by City Council as either part of the CIP/MIP budget approval or as a standalone item. - Listing of projects and amounts to be funded by ARPA is provided to Finance Manager. - Contracting - Project Manager notifies the Law Department if the resulting contract is funded by ARPA funds. - Law Department approves contracts as to form (including review of required ARPA language. - Finance Manager reviews expenditures for each project. Expenditures would have been routed to appropriate individuals and approved in the finance system. - Finance Manager determines fuding to be moved to project based on expenditures made and allocated ARPA funds remaining for project. - Project expenditures over the ARPA funding will be funded through other sources. - Finance Manager enters current quarter and life to date information into SLFRF reporting. Second quarter 2024 and future submissions will be approved by the Director of Finance and Budget prior to entering into SLFRF system.

View Audit 317392

Finding 481317 (2023-007)

Material Weakness 2023

Mesa County, Colorado

CO

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The County concurs with this finding and will be working to enhance documentation of the review of the Adoption Assistance eligibility determinations.

View Audit 317385

Finding 481316 (2023-006)

Material Weakness 2023

Mesa County, Colorado

CO

Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The County concurs with this finding and will be working to enhance documentation of the review of the IV-E eligibility determinations.

View Audit 317385

Finding 481313 (2023-004)

Material Weakness 2023

Mesa County, Colorado

CO

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

The County concurs with this finding and is refining procedures ensuring all reports, reviews, and communications are performed, reviewed, completed, and documented in a timely and accurate manner.

View Audit 317385

Finding 481292 (2023-005)

Material Weakness 2023

West Virginia School of Osteopathic Medicine Clinic, Inc. D/b/a Robert C. Byrd Clinic

WV

Allowable Costs / Cost Principles Material Weakness Reporting § 200.303

Finding 2023-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN#550559322 Federal Financial Assistance Listing #93.498 Compliance Requir...

Finding 2023-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN#550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Reporting Finding Summary: The original expenditure listing which would have included the review of the expenditure listing, was not retained. As a part of the single audit, the Clinic recreated the expenditure listing to support the expenditures reported on the special report submitted to the Department of Health and Human Services for Period 4, however there was no control in place to retain the original documentation of the determination of expenditures and their related review. In addition, there was no retained documentation of the review and approval of the Clinic’s special report submitted to the Department of Health and Human Services for Period 4 TIN #550559322. Responsible Individuals: Kayla Trent, Finance Director Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we have implemented procedures to retain expenditure listings and other support for federal awards as well as the related review. The Clinic began retaining expense reconciliations for all Grants. Anticipated Completion Date: July 1, 2024

View Audit 317379

Finding 481258 (2023-013)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement wit...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP shall recruit and hire a dedicated Data Analyst to oversee the PIC entries and to ensure that recertifications are uploaded in accordance with reporting requirements. The PIC uploads will be quality-controlled monthly by HCVP and quarterly by the Office of Audit and Compliance. The OAC will conduct monthly checks to ensure that the uploads are done to facilitate the required reporting. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.

View Audit 317348

Finding 481257 (2023-011)

Significant Deficiency 2023

District of Columbia Housing Authority

MD

Questioned Costs HUD Housing Programs Allowable Costs / Cost Principles

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend management the Authority implements controls to ensure that transfers are not made out of the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend management the Authority implements controls to ensure that transfers are not made out of the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: OFM leadership is updating the financial policies and procedures to include standard operating procedures (SOP) to accommodate the new Yardi financial software system. These SOPs will include a transfer of funds to the proper program process that will be implemented to ensure that the any fund transfer should be reviewed and approved by the financial managers. Name of the contact person responsible for corrective action: Heather Mueller. Planned completion date for corrective action plan: 09/30/2024.

View Audit 317348 Questioned Costs: $1

Finding 481256 (2023-008)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that files are maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response ...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that files are maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP is implementing a monthly quality control protocol to review new applicant files for completeness. A new Program Director was assigned to oversee this quality control process. The Program Director will also monitor the new tenant checklist which will be created to ensure that all new tenant documentation is accurately maintained. The OAC shall monitor and collaborate with the HCVP to ensure that the checklist is accurate and available for auditing. Name of the contact person responsible for corrective action: Starr Lane Planned completion date for corrective action plan: 7/31/24.

View Audit 317348

Finding 481255 (2023-007)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the rent to the owner is reasonable in accordance with their administrative plan. Explanation of disagreement with audit finding: There is no disagreement w...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the rent to the owner is reasonable in accordance with their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP hired a third-party vendor, AffordableHousing.com, to conduct all rent reasonableness of all housing units that are presented for leasing, to ensure that the rent to owner is reasonable and in accordance with the administrative plan. The OAC shall monitor the compliance monthly. Name of the contact person responsible for corrective action: Ockeshia Pompey Planned completion date for corrective action plan: 7/31/24.

View Audit 317348

Finding 481254 (2023-006)

Material Weakness 2023

District of Columbia Housing Authority

MD

Eligibility HUD Housing Programs Material Weakness

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken ...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that documentation is maintained for new tenants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP is implementing a monthly quality control protocol to review new applicant files for completeness. A new Program Director was assigned to oversee this quality control process. The Program Director will also monitor the new tenant checklist which will be created to ensure that all new tenant documentation is accurately maintained. The OAC shall monitor and collaborate with the HCVP to ensure that the checklist is accurate and available for auditing. Name of the contact person responsible for corrective action: Starr Lane. Planned completion date for corrective action plan: 7/31/24.

View Audit 317348

Finding 481253 (2023-005)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordance with their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with th...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordance with their administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP created a dedicated phone line and email address to log and document inspections weekly. A designated staff member was assigned to review all inspection reports and findings, as well as to monitor the dedicated phone line and email address on a weekly basis. The OAC shall monitor this process monthly. Name of the contact person responsible for corrective action: Joseph Atkins. Planned completion date for corrective action plan: 6/30/24.

View Audit 317348

Finding 481252 (2023-004)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements con...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP created a dedicated phone line and email address to log and document inspections weekly. A designated staff member was assigned to review all inspection reports and findings, as well as to monitor the dedicated phone line and email address on a weekly basis. The OAC shall monitor this process monthly. Name of the contact person responsible for corrective action: Joseph Atkins Planned completion date for corrective action plan: 6/30/2024.

View Audit 317348

Finding 481251 (2023-003)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Eligibility Material Weakness

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: ...

Housing Voucher Cluster – Assistance Listing Nos. 14.871/14.879 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications. Once completed, the file will be reviewed monthly by an HCVP quality control staff and quarterly by the OAC to ensure that documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24

View Audit 317348

Finding 481242 (2023-012)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreemen...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that recertifications are uploaded to PIC in accordance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP shall recruit and hire a dedicated Data Analyst to oversee the PIC entries and to ensure that recertifications are uploaded in accordance with reporting requirements. The PIC uploads will be quality-controlled monthly by HCVP and quarterly by the OAC. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24.

View Audit 317348

Finding 481241 (2023-010)

Significant Deficiency 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Reporting Significant Deficiency

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordance with their admin plan. Explanation of disagreement with audit finding: There is no disagreement with the au...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that HQS inspections are completed in accordance with their admin plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP created a dedicated phone line and email address to log and document inspections weekly. A designated staff member was assigned to review all inspection reports and findings, as well as to monitor the dedicated phone line and email address on a weekly basis. Name of the contact person responsible for corrective action: Joseph Atkins Planned completion date for corrective action plan: 6/30/24.

View Audit 317348

Finding 481240 (2023-009)

Material Weakness 2023

District of Columbia Housing Authority

MD

HUD Housing Programs Material Weakness Reporting

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that financial reporting is completed and submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding....

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority implements controls to ensure that financial reporting is completed and submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: OFM leadership is updating the financial policies and procedures to include standard operating procedures (SOP) to accommodate the new Yardi financial software system. These SOPs will include a monthly closing checklist process that will be implemented to ensure that the financial reports are prepared and submitted in a timely manner. Name of the contact person responsible for corrective action: Heather Mueller. Planned completion date for corrective action plan: 09/30/2024.

View Audit 317348

Finding 481239 (2023-002)

Material Weakness 2023

District of Columbia Housing Authority

MD

Eligibility HUD Housing Programs Material Weakness

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit find...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that DCHA staff review the controls in place to ensure that required eligibility determination documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken or planned in response to finding: The HCVP has a program eligibility team that processes applications, and once complete, the file is reviewed by a quality control and compliance officer for compliance. The Office of Audit and Compliance (OAC) shall periodically monitor this process to ensure that eligibility determination documentation is complete, accurate, and available for audit. Name of the contact person responsible for corrective action: Khaliah Payne. Planned completion date for corrective action plan: 9/30/24

View Audit 317348

Finding 481237 (2023-004)

Significant Deficiency 2023

Human Services of Faribault and Martin Counties

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

TIMELY REPORTING Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2305MN5MAP and 2305MN5ADM, 2023 Pass-Through Agency: Minnesota Departmen...

TIMELY REPORTING Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Numbers and Year: 2305MN5MAP and 2305MN5ADM, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2305MN5MAP and 2305MN5ADM Compliance Requirement Affected: Reporting Award Period: Year-Ended December 31, 2023 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the Agency implement control procedures to ensure all reports are formally reviewed and all reporting deadlines are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review procedures and implement changes as needed to ensure going forward all reports are formally reviewed and are submitted timely. Name of the contact person responsible for corrective action plan: Chera Sevcik, Human Services Executive Director Planned completion date for corrective action plan: December 31, 2024

View Audit 317344

Finding 481227 (2023-001)

Significant Deficiency 2023

Douglass Community Services, Inc.

MO

Internal Control / Segregation of Duties

We acknowledge the audit finding regarding the lack of segregation of duties. To address this issue, we have developed the following corrective action plan: 1. Risk Assessment: We will conduct a risk assessment to identify all areas with Segregation of Duty conflicts. 2. Policy Implementation: Po...

We acknowledge the audit finding regarding the lack of segregation of duties. To address this issue, we have developed the following corrective action plan: 1. Risk Assessment: We will conduct a risk assessment to identify all areas with Segregation of Duty conflicts. 2. Policy Implementation: Policies will be evaluated and will be established to clearly define roles and responsibilities, ensuring no single individual controls multiple aspects of critical financial transactions. 3. Duty Reassignment: We have also hired another position in the finance department with the start date of August 7, 2024. Responsibilities will be assigned amount staff to eliminate conflicts. 4. Training: Employees will receive training on the importance of Segregation of Duties and their specific roles under the new framework. 5. Monitoring: Regular internal audits and continuous monitoring will be implemented to ensure compliance with the new Segregation of Duties policies. We anticipate completing these actions by September 30, 2024. Responsible Party is Stephanie Cooper, Chief Executive Officer

View Audit 317343

Finding 481219 (2023-002)

Material Weakness 2023

City of Gloucester, Massachusetts

MA

Material Weakness Reporting Program Income § 200.328

Condition: The City did not prepare and file the four required quarterly Project and Expenditure reports for fiscal year 2023. Corrective Action Planned: The City has prepared and filed the Project and Expenditure reports for fiscal years 2023 and 2024. The City has implemented procedures to prepa...

Condition: The City did not prepare and file the four required quarterly Project and Expenditure reports for fiscal year 2023. Corrective Action Planned: The City has prepared and filed the Project and Expenditure reports for fiscal years 2023 and 2024. The City has implemented procedures to prepare and file the four required quarterly Project and Expenditure reports by the required deadline. We feel the finding has been resolved going forward. Anticipated Completion Date: June 30, 2024 Contact: Conor MacCorkle, City Chief Financial Officer

View Audit 317341

Finding 481214 (2023-002)

Material Weakness 2023

St. Sharbel's Maronite Housing Corporation Project No. 072-11136ref

IL

Internal Control / Segregation of Duties

Jeff Cottingham, Management agent and Father Elia, sponsor of project will continue to monitor financial reports and accounting information as correction is not practical

View Audit 317339

Finding 481213 (2023-001)

Material Weakness 2023

St. Sharbel's Maronite Housing Corporation Project No. 072-11136ref

IL

Internal Control / Segregation of Duties HUD Housing Programs

Jeff Cottingham, Management agent and Father Elia, sponsor of project, will be responsible for monitoring monthly financial results and accounting information as correction is not practical.

View Audit 317339

Corrective Action Plans

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