Corrective Action Plans

Finding 501230 (2023-001)

Material Weakness 2023

Logan Health

MT

Internal Control / Segregation of Duties Material Weakness Reporting

Finding 2023-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Federal Agency Name: Department of Health and Human Services Program Name: Activities to Support St...

Finding 2023-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Federal Agency Name: Department of Health and Human Services Program Name: Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Federal Assistance Listing: #93.391 Finding Summary: During the course of our engagement, we noted a material program missing from the Schedule that was not identified by management. Responsible Individuals: Kevin Abel, CEO and Brigid Burke, CFO Status: Procedures and controls over tracking and recording of federal programs with the Schedule will be updated in order to provide a complete Schedule. Anticipated Completion Date: 12/31/2024

View Audit 323504

Finding 501225 (2023-007)

Material Weakness 2023

State of Alabama

AL

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

Finding: According to the Uniform Guidance, 2 CFR 200.303 (a), non-Federal entities receiving Federal awards must establish and maintain effective internal controls over these awards. These controls must provide reasonable assurance that the entity manages the Federal award in compliance with applic...

Finding: According to the Uniform Guidance, 2 CFR 200.303 (a), non-Federal entities receiving Federal awards must establish and maintain effective internal controls over these awards. These controls must provide reasonable assurance that the entity manages the Federal award in compliance with applicable Federal statutes, regulations, and the terms and conditions of the award. A fundamental objective of an effective internal control system is to ensure that information is accurate and reliable, which includes a thorough review and approval process. The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, May 2023, requires the Alabama Department of Labor to ensure an employer’s experience rating is properly applied, as the employer’s “experience” with the unemployment of former employees is the dominant factor in the computation of the employer’s annual state Unemployment Insurance tax rate. The Alabama Department of Labor was unable to provide audit documentation to support their review and approval of employer experience rated tax rates. The Alabama Department of Labor did not have policies and procedures in place to document the review and approval of the employer experience rated tax rates. As a result, the employer experience related tax rates could be incorrect, resulting in potential overpayments or underpayments of taxes. Recommendation: The Alabama Department of Labor should develop and document internal controls over employer experience rated tax rates to help ensure they are accurate and properly applied. Response/Views: ADOL does not agree with this finding as explained in the Request for Views CAP letter. Corrective Action Planned: Procedures were in place to ensure accuracy of information. However, the support documentation of this verification was not retained during the time of this review. Anticipated Completion Date: Additional processes to retain support documentation of this verification have already been implemented. Contact Person(s): Thomas Daniel, ADOL Unemployment Compensation Division Director

View Audit 323486

Finding 501221 (2023-003)

Significant Deficiency 2023

State of Alabama

AL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding: 45 CFR Section 261 .63 requires the Alabama Department of Human Resources to submit a Work Verification Plan to the U.S. Department of Health and Human Services (HHS) for approval. The Alabama Department of Human Resources must comply with its approved Work Verification Plan to ensure accur...

Finding: 45 CFR Section 261 .63 requires the Alabama Department of Human Resources to submit a Work Verification Plan to the U.S. Department of Health and Human Services (HHS) for approval. The Alabama Department of Human Resources must comply with its approved Work Verification Plan to ensure accuracy in reporting work activities by work eligible individuals on the Temporary Assistance for Needy Families (TANF) Data Report. Data for work participation activities are used in calculating work participation rates. During our testing of 25 TANF cases, we found two cases in which the hours reported for an individual participating in a work activity were inaccurate. The Department of Human Resources failed to ensure accuracy of data for work participation activities which may result in an inaccurate work participation rate. This is a significant deficiency in internal controls. The Department of Human Resources did not have adequate procedures in place to ensure that the information included on the TANF Data Report is accurate. Recommendation: The Department of Human Resources should establish and maintain effective internal controls to ensure accuracy in reporting work activities by work-eligible individuals on the TANF Data Report. Response/Views: We disagree. The finding statement declares that the Department of Human Resources failed to ensure accuracy of data for work participation activities which may result in an inaccurate work participation rate. This is a significant deficiency in internal controls. The Department of Human Resources did not have adequate procedures in place to ensure that the information included on the TANF Data Report is accurate. We do agree with the findings of two cases "in which the hours reported for an individual participating in a work activity were inaccurate." We agree that the 2 of the 25 cases selected had the incorrect frequency for the number of employment hours entered which could potentially affect the work participation rate for Alabama. Corrective Action Planned: The two cases which involved an error in the frequency of the hours reported appear to be isolated and inadvertent in nature. Our policy requires verification and calculation of employment hours at the beginning of employment and reverification and calculation of employment hours in the fifth month of employment. Based on our JOBS policy, your review of 25 cases, potentially represents up to 200 calculations and your findings indicate only 2 calculation errors. Furthermore, our research indicates that the errors in the two cases addressed in your findings did not have an affect on the State's overall Work Participation Rate. Additionally, we believe our supervisory reviews as well as a percentage of record rereviews remain the best way to monitor accuracy of information entered in our system while basic and refresher training remains the course of prevention for information prior to entry into the system. Basic training for each new employee involves two weeks of intense, in person, interactive training. Refresher training or one to one support is provided as needed or requested by county staff. The official policy and automation helpdesk are staffed by specialists, who responds to questions daily. County consultants also perform re-reviews of the county's reviews and provide guidance as observed or requested. The stated purpose of these processes is to ensure systematic review of the work done in the family assistance program; to identify worker problems; to identify error trends and concentrations; and to monitor program performance. At the county level information from that process can be used for worker performance assessment, local corrective action, to train new workers, to identify areas of strengths and weaknesses of staff. At the State level the process provides information to monitor program performance to include identifying problems and error trends by county, region and statewide. Analysis of this data provides a way to determine training needs and to evaluate performance standards and the impact of program changes. The Division case record re-review process of the work of the supervisor provides yet another level of oversight to address the issues. Resulting corrective action from these reviews both at the County and State Office level can include additional individual worker or general staff training, program clarifications, as well as attention to the specific cases identified. Longstanding practice of such activity and experience tells us the process does prevent, detect, and correct errors. These errors have been discussed with the county worker and supervisor for case corrective action. Finally, DHR is in the final stages of development of a new TANF and JOBS system and we have requested that the hours of participation field require a question regarding the frequency of hours listed. Anticipated Completion Date: December 31, 2024. Contact Person(s): Fannie Ashley or Tessa Mitchell

View Audit 323486

Finding 501207 (2023-004)

Significant Deficiency 2023

Shasta Regional Transportation Agency

CA

Cash Management Reporting Significant Deficiency

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant ...

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant Deficiency over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Delay in Caltrans approving the first quarter request for reimbursement and progress reports until January 24, 2023, as well as additional staff time needed to prepare the narrative information, resulted in the submittal of the second quarter reports nine days after the due date of January 30, 2023. Caltrans District 2 staff were notified early that there would be a delay in the reporting and indicated this was acceptable. This is an extraordinary occurrence, as it is SRTA’s common practice to submit all required reports before the deadline. Corrective Action Plan: The Agency will send a memorandum to all staff to ensure timely reporting of required quarterly reports in accordance with the agency’s established policies and procedures and compliance with the Master Fund Transfer Agreement that is active at the time of submittal. The Agency will also create reminders on the shared agency calendar that will be set to automatically alert the executive director, CFO, OWP manager, and relevant staff, of the deadline to submit the quarterly narratives to further eliminate the risk of late reporting. Responsible Individual(s): Sean Tiedgen, Executive Director and Jessica Carlson, Chief Fiscal Officer Anticipated Completion Date: June 30, 2024

View Audit 323480

Finding 501204 (2023-001)

Significant Deficiency 2023

Church Housing for Fairfield, Inc.

CT

HUD Housing Programs Internal Control / Segregation of Duties

Finding 2023-001: The Organization did not retain a printed and dated copy of the Failed Verification and Failed EIV Prescreen reports for two out of twelve months of the year. Recommendations (2023-001-a): Auditor recommends that management reevaluate its system and procedures to ensure that the ...

Finding 2023-001: The Organization did not retain a printed and dated copy of the Failed Verification and Failed EIV Prescreen reports for two out of twelve months of the year. Recommendations (2023-001-a): Auditor recommends that management reevaluate its system and procedures to ensure that the required reports are printed and retained on the required schedule with clear dates of printing, going forward. View of Responsible Officials: Management concurs with this finding and agrees with the auditor’s recommendation. Management considers corrective action to be completed and will reevaluate its system to ensure future compliance.

View Audit 323476

Finding 501157 (2023-001)

Material Weakness 2023

Rappahannock Goodwill Industries, Inc.

VA

Internal Control / Segregation of Duties Reporting

Management was able to see deficiencies in the finance and accounting department in 2023. There was turnover of several staff, and in December 2023 the VP of Finance was removed from the position and a new qualified CFO was hired in mid-January 2024. An accounting and consulting firm, Cherry Bekae...

Management was able to see deficiencies in the finance and accounting department in 2023. There was turnover of several staff, and in December 2023 the VP of Finance was removed from the position and a new qualified CFO was hired in mid-January 2024. An accounting and consulting firm, Cherry Bekaert was hired in early January 2024 to assist with bringing the accounting and financial systems up to GAAP standards. In addition, the GL accountant position has been upgraded in 2024 to a Senior Accountant position and new qualified staff have been hired to continue to allow for internal controls. The AR and AP positions continue so that there is separation of duties as well. Additionally, management decided in 2023, to move away from the accounting system ‘Traverse’ that was very difficult to navigate and was antiquated in its functioning. The new Sage Intacct accounting software was implemented in 2024. Cherry Bekaert was hired and under the direction of the new CFO the implementation was completed on May 1, 2024. SAGE Intacct has made the accounting process much more efficient to enable proper functioning of the accounting department. Moving forward, the intention is to continue the assistance of the consulting firm, as a long-term consulting partner, to complete reconciliations and to ensure stability if there is staff turnover. This also ensures oversight and corrections of processes monthly.

View Audit 323413

Finding 501146 (2023-005)

None 2023

Houston Housing Authority

TX

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

2023-005 Special Tests and Provisions – Waiting List Moving to Work Demonstration Program AL No. 14.881 Other Matter to be Reported Under the Uniform Guidance Condition: While testing of applicants that reached the top of the waiting list during the year ended December 31, 2023, the Authority was u...

2023-005 Special Tests and Provisions – Waiting List Moving to Work Demonstration Program AL No. 14.881 Other Matter to be Reported Under the Uniform Guidance Condition: While testing of applicants that reached the top of the waiting list during the year ended December 31, 2023, the Authority was unable to provide sufficient documentation for one of the applicants to support their position on the list. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to waiting list selection process and document retention requirements. Action Taken: The Houston Housing Authority agrees with this finding. A review of existing procedures revealed that there were issues with the management of the waiting lists. The Houston Housing Authority is transitioning to a new software program during 2024. One of the reasons for the implantation of the new software is to make use of a better wait list management feature that is available within the new software. Waitlists have been reviewed and purged of stale an do dated information which will facilitate better management of the waitlist for future periods.

View Audit 323395

Finding 501145 (2023-004)

Material Weakness 2023

Houston Housing Authority

TX

HUD Housing Programs Eligibility Material Weakness

2023-004 Eligibility Section 8 Project-Based Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 670 of tenants, 20 tenant files were tested and the following deficiencies were noted: • Nine files did not have annual recertification...

2023-004 Eligibility Section 8 Project-Based Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 670 of tenants, 20 tenant files were tested and the following deficiencies were noted: • Nine files did not have annual recertifications performed during the year, • Eight files did not have 9886 release of information forms within 15 months of annual recertification, • Six files did not have an annual recertification performed within 12 months, • Six files did not have documentation necessary to verify the reported income, and • Three files did not have a 214 declaration form for all members of the household. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024

View Audit 323395

Finding 501144 (2023-003)

Material Weakness 2023

Houston Housing Authority

TX

HUD Housing Programs Eligibility Material Weakness

2022-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 484 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 4 tenants selected for ...

2022-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 484 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 4 tenants selected for testing): • One file did not have an annual recertification performed during the year, • One file did not have an annual recertification performed within 12 months, • Two files did not have 9886 release of information forms within 15 month of the annual recertification, • One file did not have a 214 declaration form for all members of the household, and • One file did not have documentation necessary to verify the reported income. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have an annual recertification performed within 12 months, • Three files did not have a 214 declaration form for all members of the household, • Four files did not have 9886 release of information forms within 15 month of the annual recertification, and • Five files did not have rent reasonableness form performed for the annual certification. The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024. FINDINGS - FEDERAL AWARD PROGRAMS AUDIT 2023-003 Eligibility Housing Voucher Cluster Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 1,500 of Housing Voucher Cluster tenants the following deficiencies were noted: Mainstream Voucher AL #14.879 (a total of 5 tenants selected for testing): • Five files did not have supporting documents needed to determine eligibility. Emergency Housing Voucher AL #14.871 (a total of 5 tenants selected for testing): • Four files did not have supporting documents needed to determine eligibility, and • One files did not have an annual recertification performed. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected in the third quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that a HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the third quarter of 2024.

View Audit 323395

Finding 501143 (2023-002)

Material Weakness 2023

Houston Housing Authority

TX

HUD Housing Programs Eligibility Material Weakness

2023-002 Eligibility Moving to Work Demonstration Program AL No. 14.881 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 18,300 of Section 8 Housing Choice Voucher and 2,300 Low Rent Public Housing tenants the following deficiencies were n...

2023-002 Eligibility Moving to Work Demonstration Program AL No. 14.881 Material Weakness in Internal Control Material Noncompliance Condition: Out of an approximate population of 18,300 of Section 8 Housing Choice Voucher and 2,300 Low Rent Public Housing tenants the following deficiencies were noted: Section 8 Housing Choice Voucher (a total of 40 tenants selected for testing): • Thirty-five files did not have annual recertifications performed during the year, • Nine files did not have 9886 release of information forms within 15 months of annual recertification, • Four files did not have a annual recertification performed with 12 months of the previous certification, • Three file did not have an inspection performed during the year • Three files did not have documentation necessary to verify the reported income, • Two files did not have a 214 declaration for a member of the household, and • Two files did not have documentation necessary to verify custody of dependents. Low Rent Public Housing (a total of 40 tenants selected for testing): • Fourteen files did not contain flat rent options forms, • Ten files did not have documentation necessary to verify the reported income, • Seven files did not have the annual recertification performed or documented, • Five files did not have a 214 declaration for a member of the household, • Three files did not have support necessary to verify income allowances, • Two files did not have 9886 release of information form within 15 months of the annual recertification, and • One file did not have annual recertifications performed within 12 months of the previous annual certification. Auditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: The Houston Housing Authority agrees with this finding. The Houston Housing Authority has for the past several months undertaken a program to review all voucher files for purposes of getting all delinquent recertifications completed. During this process if other required documents are found to be missing steps are being taken to complete the missing documentation and make sure that the files are complete. This review is substantially completed with final completion expected during the final quarter of 2024. Procedures have been implemented with regards to preventing this situation from recurring. Where needed staff will be provided the necessary training to make sure that all HCVP staff have the skills needed to successfully complete their job tasks. To facilitate this training, the Houston Housing Authority has created a training center that is made available to not only Houston Housing Authority staff but also others to provide a wide variety of training classes. Current leadership at the Houston Housing Authority is committed to having a competent trained staff working in the HCVP as well as other departments with the agency. Because the file clean up work was being performed in calendar year 2024 we expected this finding would be present for the 2023 audit. This work is handled by the Voucher Program Operations department. The VP of this department and the Director of this department are primarily responsible for making sure the necessary corrections are made and the fill review is completed within the final quarter of 2024.

View Audit 323395

Finding 501142 (2023-001)

Material Weakness 2023

Houston Housing Authority

TX

Internal Control / Segregation of Duties HUD Housing Programs Material Weakness

2023-001 Financial Reporting – Disclaimer of Opinion Material Weakness in Internal Control Material Noncompliance Condition: During our audit of the Authority’s financial statements, numerous adjustments were needed to properly report the financial statements in accordance with generally accep...

2023-001 Financial Reporting – Disclaimer of Opinion Material Weakness in Internal Control Material Noncompliance Condition: During our audit of the Authority’s financial statements, numerous adjustments were needed to properly report the financial statements in accordance with generally accepted accounting principles. Certain accounts had not been properly reconciled and corrective entries were not readily available. Significant audit adjustments were necessary for several audit areas and the audit was significantly delayed due to these adjustments. Given the amount of adjustments needed the auditor did not have enough time to complete the necessary audit procedures and as such have issued a disclaimer of opinion on the financial statements. Auditor’s Recommendations: The Authority should continue to develop and implement internal controls over both internal and external reporting, and the year-end close process to ensure reporting remains accurate and timely, with any unexpected financial data being investigated and corrected before it is reported. The Authority should consider additional staff training on development activities. Action Taken: The Houston Housing Authority agrees with this finding and related recommendations. During this audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. We are in the process of bringing in additional staff to expand the capacity of the Finance department. As we had fallen behind on our audits we anticipated the weaknesses noted in prior audits would continue to be present in future audits including the 2023 audit. We have been working very diligently to address the issues within the finance department that gave rise to this finding. We fully expected this finding or a similar finding to be present for the 2023 audit as many of the departmental improvements and changes were not in place during the 2023 calendar year. We have also been somewhat limited in the time available to implement changes as we have been working on clearing up the prior audit delinquencies since hiring out new outside auditors. This will be the first time in years where we will have a prior year audit available to us prior to the end of the current year. We will be able to have any 2023 audit adjustments posted to the general ledger prior to yearend 2024 so many of the reconciliation issues that have been encountered on the prior audits are not expected to be present when we move into the 2024 audit. The VP Fiscal and Business Operations as well as the Director of Finance are responsible for implementing the necessary process and procedural changes to eliminate the need for this type of finding for the 2024 audit.

View Audit 323395

Finding 501135 (2023-002)

Significant Deficiency 2023

Georgia Alliance of Boys & Girls Clubs, Inc.

GA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.305

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal fun...

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

View Audit 323392

Finding 501134 (2023-001)

Significant Deficiency 2023

Georgia Alliance of Boys & Girls Clubs, Inc.

GA

Internal Control / Segregation of Duties Reporting § 200.328 § 200.329

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Corrective Action: The Alliance will enhance its procedures and internal controls to ensure that records of report submission are appropriately retained. Anticipated Completion Date: December 31, 2024

View Audit 323392

Finding 501131 (2023-001)

Significant Deficiency 2023

Indiana Alliance of Boys and Girls Clubs, Inc.

GA

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.305

Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds...

Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

View Audit 323389

Finding 501085 (2023-001)

Significant Deficiency 2023

Brighter Tomorrows, Inc.

NY

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

2023-001. Written Policies United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization did not have writt...

2023-001. Written Policies United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization did not have written policies referencing these requirements. Recommendation: The Organization should update their policies and procedures manual to ensure compliance with the procurement requirements at 2 CFR 200.317-327, and the impact of 24 CFR 578.103(c). Corrective Action: The Organization will update the written policies and procedures to comply with the Uniform Guidance requirements. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

View Audit 323358

Finding 501065 (2023-001)

None 2023

Foundation for Puerto Rico, Inc.

PR

Reporting Internal Control / Segregation of Duties § 200.512

Management Response: This finding was identified for the submission of the 2021 Data Collection Form, and by the time the Organization established procedures to ensure that the Data Collection Form and Single Audit report are submitted within the established due date, the due date of the 2022 audit ...

Management Response: This finding was identified for the submission of the 2021 Data Collection Form, and by the time the Organization established procedures to ensure that the Data Collection Form and Single Audit report are submitted within the established due date, the due date of the 2022 audit already passed. However, the procedures will be in place for the next year’s audit to avoid the recurrence of this finding.

View Audit 323328

Finding 501047 (2023-004)

Significant Deficiency 2023

Grand Forks County

ND

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

Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal c...

Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal control process to verify all requisition slips get signed. Anticipated Completion Date Fiscal Year 2024

View Audit 323296

Finding 501044 (2023-001)

Significant Deficiency 2023

Community Medical Wellness Centers USA

CA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into ...

Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into place a monthly audit for ensuring compliance to the sliding fee discount policy. Responsible persons: Nichole Henderson, Quality Improvement Quality Assurance Director and Demetria Johnson, Billing Manager will be in charge of implementing the corrective action. Expected Implementation Date: Started August 1, 2024.

View Audit 323284 Questioned Costs: $1

Finding 501023 (2023-005)

Material Weakness 2023

Family Service Association of Howard County

IN

HUD Housing Programs Period of Performance Matching / Level of Effort / Earmarking § 200.303

We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have imp...

We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have implemented a process that all grant claims/payment vouchers are formerly reviewed and initialed by our Executive Director.

View Audit 323260

Finding 501012 (2023-003)

Material Weakness 2023

Umpqua Public Transportation District

OR

Subrecipient Monitoring Cash Management Material Weakness § 200.302

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and e...

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. The reimbursement reports were to be reviewed by the District Manager prior to submission. Approval of the reimbursement requests and supporting reports by the District Manager were often delayed. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper financial reporting. Lack of timely filing of reimbursement requests could result in overstating accounts receivable balances and critical revenues lost due to cutoff terms of the grant award. Questioned Cost: No Context: Delays in filing reimbursement claims and internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures resulted in lost revenues and delayed recognition of revenue, which required adjustments to correct the financial statements. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2022-001 Recommendation: The District should establish a more simplified and effective process for the review and approval of GAAP basis reporting and grant reimbursement requests and grant reporting. As part of this process, supporting general ledger reports and supporting data should be subject to a qualified individual to review and approval on a timely basis. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

View Audit 323248

Finding 500934 (2023-003)

Significant Deficiency 2023

Wabanaki Health and Wellness

ME

Significant Deficiency Internal Control / Segregation of Duties

2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management ...

2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management system, NetSuite. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks, and the NetSuite changes would have demonstrated our corrective action for the segregation of duties, since this was part of the software’s functionality. However, we encountered several issues with the implementation of the new system and WPHW decide to move away from NetSuite in May 2024. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. WPHW has implemented the following process to ensure the separation of duties: 1) AR/AP Specialists and Accounting Specialists will have access to the accounting software and will not have any access to the bank accounts for entry of information. 2) Accountants, Accounting Manager and AR/AP Manager will have read-only access to the bank accounts and full access to the accounting software to verify and review day-to-day transactions. 3) The Director of Accounting will have full access to the bank and review only access to the accounting software to do the proper review process. 4) Tasks can be handed off between staff within each level, but to ensure appropriate separation of duties, task cannot cross levels With these implemented there will be clear separation of duties this will allow mitigating of procedures to be formed by somebody who has full access to both systems to help ensure that there is no cross between any possible chance of fraud and decrease risk of significant errors and/or misstated financial statements. Access for the Director of Accounting to make adjustments will be cut off by October 1, 2024, at which time the process will be fully implemented. With this process in place, we anticipate this issue being fully resolved in FY25.

View Audit 323235

Finding 500933 (2023-002)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our...

2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our year-end processes and acknowledges that there is additional improvement needed. For FY23, WPHW created a year-end check list and started the review process. Unfortunately, due to staff absences and NetSuite issues, we were not able to fully implement these changes. Both situations have provided us with lessons learned for how to correctly implement changes in the future. For FY24, WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY24.

View Audit 323235

Finding 500932 (2023-001)

Material Weakness 2023

Wabanaki Health and Wellness

ME

Material Weakness Internal Control / Segregation of Duties

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new ...

2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new processes that would have fully addressed prior concerns. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks. However, we encountered several issues with the implementation of the new system, which delayed prior year corrected actions. In May 2024, WPHW decide to no longer work with NetSuite, due to the number of issues with the system and the company. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. At the time of the transition back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and two new managers, AR/AP Manager and Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or AR/AP Manager identifying need for a journal entry 2) Accounting Specialist or AR/AP Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accountant or Accounting Manager reviews packet and determines who can enter journal a. If reviewed by Accountant, entry is entered QuickBooks by Accounting Specialist b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process will be implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.

View Audit 323235

Finding 500928 (2023-001)

Material Weakness 2023

Houston Area Urban League

TX

Reporting Internal Control / Segregation of Duties

RE: Management Response to 2023 Annual Audit We acknowledge the observations and recommendations made during the Houston Area Urban League's 2023 Annual Audit. The Board of Directors Audit Committee and the Houston Area Urban League's Executive Leadership Team have reviewed the recommendations. In r...

RE: Management Response to 2023 Annual Audit We acknowledge the observations and recommendations made during the Houston Area Urban League's 2023 Annual Audit. The Board of Directors Audit Committee and the Houston Area Urban League's Executive Leadership Team have reviewed the recommendations. In response to the recommendation, we have outlined the action items to support implementation. A review and update of our Financial Policies and Procedures and the Finance Manual is scheduled for completion by year-end. Simultaneously, as we deploy innovative technology to streamline operations and drive efficiencies, we will document workflow procedures to ensure compliance and controls. A key element to defining the written procedures will be the validation of process controls. The target date for completion is December 31 , 2024. As we analyze organizational changes that will ensure the adherence to the recommendations, we are assured that the finance team is knowledgeable of their respective roles and responsibilities to adequately perfonn duties. In response to the recommendations related to the Schedule of Expenditures of Federal A wards, (SEF A) we have designated a Grants Analyst who is responsible for ensuring the adhering to SEFA requirements as a component of the month-end closing process. We will also reference SEF A for recording of journal entries and the reconciliation process. Lastly, the Finance Department will also establish reviews with the Board of Directors ' Audit Committee and Finance Committee to simulate a high-level audit process. This review should support the identification of potential areas of concern for immediate resolution.

View Audit 323231

Finding 500927 (2023-001)

Material Weakness 2023

Coquille Watershed Association

OR

Material Weakness Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trai...

Views of Responsible Officials and Planned Corrective Actions - We agree with this finding. CoqWA was successful in hiring an Executive Director in 2023, and an Office Manager in 2024 who provides bookkeeping services. Training was provided to both employees, and CoqWA will continue to schedule trainings for new staff with an emphasis on accrual accounting for the Office Manager who performs the bookkeeping function.

View Audit 323230

Corrective Action Plans

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