Corrective Action Plans

Finding 555755 (2023-001)

Material Weakness 2023

IL

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

The Finance Team has developed and deployed a comprehensive month-end close process that includes: • A detailed procedural checklist with clearly defined responsibilities • Specific deadlines for each critical task in the close sequence • Formal approval requirements at key control points • A target...

The Finance Team has developed and deployed a comprehensive month-end close process that includes: • A detailed procedural checklist with clearly defined responsibilities • Specific deadlines for each critical task in the close sequence • Formal approval requirements at key control points • A targeted completion timeline of 30 days post month-end To support this enhanced process, we have strategically increased resources within the finance function, including additional staff allocation to high-priority areas. Furthermore, we are conducting a thorough assessment of automation opportunities throughout our accounting workflow to improve efficiency, reduce manual processing, and accelerate the completion of key accounting tasks.

View Audit 354409

Finding 555627 (2023-008)

Material Weakness 2023

Sullivan County Community College

NY

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

The Vice President of Administrative Services will seek to add staff to the finance department to support grant initiatives. During FY 24‐25 a grant policy will be developed and effort be made to communicate each grant initiative as it becomes available, to the Executive Council. This process and st...

The Vice President of Administrative Services will seek to add staff to the finance department to support grant initiatives. During FY 24‐25 a grant policy will be developed and effort be made to communicate each grant initiative as it becomes available, to the Executive Council. This process and staffing update will help the college provide more detail, accuracy and controls over grants. This will be accomplished by 8/31/24.

View Audit 354200

Finding 555618 (2023-001)

Material Weakness 2023

Okanogan County

WA

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

The County did experience issues with the reporting portal for these funds. When we requested assistance, we received generic responses and little assistance from the Treasury. It wasn’t until November 2024 that we were finally able to gain the assistance we needed to gain full access to the Treas...

The County did experience issues with the reporting portal for these funds. When we requested assistance, we received generic responses and little assistance from the Treasury. It wasn’t until November 2024 that we were finally able to gain the assistance we needed to gain full access to the Treasury portal as well as some guidance on the reports. On January 1, 2025, the Treasury provided guidance that is helpful to us in understanding the reporting requirements. Now that we have the access and guidance we need, all reports will be submitted accurately and on time.

View Audit 354181

Finding 555586 (2023-010)

Material Weakness 2023

City of Espanola

NM

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.327

2023‐010 Procurement (Material Weakness/ Material Non‐Compliance): Since taking office in fiscal year 2024, the current Finance Director has implemented a Standard Operating Procedure (SOP) in alignment with the Procurement Policy adopted in 2022 to ensure compliance with the State Procurement Code,...

2023‐010 Procurement (Material Weakness/ Material Non‐Compliance): Since taking office in fiscal year 2024, the current Finance Director has implemented a Standard Operating Procedure (SOP) in alignment with the Procurement Policy adopted in 2022 to ensure compliance with the State Procurement Code, internal controls, and the proper segregation of duties in procurement. This SOP outlines the specific roles and responsibilities of the Certified Procurement Officer (CPO), Finance Director, City Manager, and City Council when applicable in the procurement process. In addition, a procurement workflow has been created to be utilized by the (CPO) to ensure compliance with the City of Espanola’s procurement policy, the State Procurement Code, and appropriate checks and balances at varying thresholds. The (CPO) is responsible for ensuring all policies and state procurement laws are followed throughout the process. Additionally, all documentation from initiation to the issuance of a Purchase Order (PO) is retained electronically in a complete packet for record-keeping and audit purposes. In order to address direct payment voucher controls, the City has restricted the use of direct payment vouchers for high-volume purchases. All procurements must follow the purchase order process, unless an exception is authorized in accordance with policy. The finance department has also implemented issuing procurement violations to any department head or staff who authorizes a purchase in the absence of an approved purchase order, which aligns with the 2022 Adopted Procurement Policy. By enforcing these measures, the City ensures procurement policy compliance, transparency, and financial accountability, thereby addressing the audit findings and preventing future violations.

View Audit 354071

Finding 555514 (2023-010)

Significant Deficiency 2023

Sacramento Housing and Revelopment Agency

CA

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

Recommendation: We recommend that the Agency reviews the controls in place to ensure that wage rate requirements are met. 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 b...

Recommendation: We recommend that the Agency reviews the controls in place to ensure that wage rate requirements are met. 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. Specifically, we are enhancing our internal controls and began developing a comprehensive technical procedure manual that will serve as a detailed guide that provides a clear reference for Procurement and Program Administration to ensure consistency, compliance. Name(s) of the contact person(s) responsible for corrective action: Christine Weichert, Director of Development Planned completion date for corrective action plan: December 31, 2025

View Audit 354004

Finding 555501 (2023-007)

Material Weakness 2023

Sacramento Housing and Revelopment Agency

CA

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

Emergency Solutions Grants Program – Assistance Listing No. 14.231 Recommendation: We recommend that the Agency reviews the controls in place to ensure that subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no disagreeme...

Emergency Solutions Grants Program – Assistance Listing No. 14.231 Recommendation: We recommend that the Agency reviews the controls in place to ensure that subrecipient payments are paid timely and within program requirements. 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. Specifically, we are enhancing our internal controls and began developing a comprehensive technical procedure manual that will serve as a detailed guide that provides a clear reference for finance and accounting staff to ensure consistency, compliance and efficiency in financial operations. Additionally, as SHRA is filling vacancies due to significant turnover across the entire Finance Department, specific training is provided to new employees in the following areas: • Building HOME • Capital Fund • CDBG • Continuum of Care • Developing a Cost Allocation Plan • Financial Management Part I and Part II (for CPD programs) • HCV Two Year Tool • IDIS • Mainstream Vouchers • Overview of Asset Management • PHA Financial Management 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

Finding 555499 (2023-005)

Significant Deficiency 2023

Sacramento Housing and Revelopment Agency

CA

HUD Housing Programs Subrecipient Monitoring Eligibility

Recommendation: We recommend 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...

Recommendation: We recommend 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. Staff developed a Public Housing File Order Checklist, written Standard operating Procedures (SOP’s) for interviewing tenants; conducting income examinations and re-examinations; verifying income eligibility using third-party verification; and determining income eligibility and calculating the tenant’s rent payment. Additionally, SHRA developed an Intake Caseworker Training Schedule to assist staff with accurately determining program eligibility. Detailed supporting documentation can be found at the following link: https://sachousing.box.com/s/or3rc8z1hml3hhxmp9f0e2t31yv6odyo 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

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

Corrective Action Plans

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