Corrective Action Plans

Finding 520767 (2022-006)

Significant Deficiency 2022

ND

Eligibility HUD Housing Programs Significant Deficiency

The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions.

View Audit 340568

Finding 520766 (2022-005)

Material Weakness 2022

Housing Authority of Cass County

ND

Material Weakness Internal Control / Segregation of Duties § 200.303

The Authority will review its policies and procedures over program compliance requirements and monitoring of program activity.

View Audit 340568

Finding 520712 (2022-011)

Material Weakness 2022

City of Abbeville, Georgia

GA

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties

Management concurs with the audit finding. The City will design and implement controls to ensure that federal awards are expended only for allowable activities.

View Audit 340445

Finding 520665 (2022-009)

Significant Deficiency 2022

Yankton Sioux Tribe

SD

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.313

2022 – 009: Activities Allowed and Unallowed, Allowable Costs, Period of Availability (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008 and 2021-007) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Cons...

2022 – 009: Activities Allowed and Unallowed, Allowable Costs, Period of Availability (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008 and 2021-007) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 15.030 Indian Law Enforcement ALN 93.575 Child Care and Development Block Grant ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, we selected 120 transactions for testing from each major program. The following number of transactions were not provided for our review during the audit: ALN 93.441 – Indian Self Determination – 47 transactions ALN 20.205 – Highway Planning and Construction - 11 transactions ALN 15.030 – Indian Law Enforcement – 8 transactions ALN 93.575 – Child Care and Development Block Grant – 22 transactions ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds – 9 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year.

View Audit 340378 Questioned Costs: $1

Finding 520598 (2022-002)

Material Weakness 2022

Unity Medical Center INC

TN

Reporting Internal Control / Segregation of Duties § 200.303 § 200.512

Setion 200.507 of the Uniform Guidance states that the single audit shall be completed, and reporting submitted with the earlier of 30 calendar days after receipt of the auditors' report, or nine months after the end of the fiscal year unless a longer period is specified. Going Forward, from 2024 w...

Setion 200.507 of the Uniform Guidance states that the single audit shall be completed, and reporting submitted with the earlier of 30 calendar days after receipt of the auditors' report, or nine months after the end of the fiscal year unless a longer period is specified. Going Forward, from 2024 we will complete our audits and submit the required reports by the deadlines.

View Audit 340225

Finding 520574 (2022-001)

Material Weakness 2022

Young Mens Christian Association of Boulder Valley

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Complete documentation to support certain payroll transactions was not available. We were able to verify the existence of the employee and rate of pay for the periods for which complete records were not available. We were also able to verify that the amounts charged were reasonable based on the natu...

Complete documentation to support certain payroll transactions was not available. We were able to verify the existence of the employee and rate of pay for the periods for which complete records were not available. We were also able to verify that the amounts charged were reasonable based on the nature of the program as well as subsequent activity. As a result, we considered the total costs charged to the program to be reasonable. However, internal controls were not in place related to the proper retention of records.

View Audit 340171

Finding 520375 (2022-005)

Significant Deficiency 2022

Trumbull Community Action Program

OH

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022 – 005 – ALN 21.023 EMERGENCY RENTAL ASSISTANCE PROGRAM (CAA-HRG) – The financial reports are prepared by the Chief Financial Officer with no review of the reporting process by a second prior to submission.” CORRECTIVE ACTION – 2022 – 05: As suggested by the auditing firm, a formal r...

Finding 2022 – 005 – ALN 21.023 EMERGENCY RENTAL ASSISTANCE PROGRAM (CAA-HRG) – The financial reports are prepared by the Chief Financial Officer with no review of the reporting process by a second prior to submission.” CORRECTIVE ACTION – 2022 – 05: As suggested by the auditing firm, a formal review process is in place that is being followed to ensure that the reports are properly prepared. This process requires a secondary review by another responsible agency employee who will provide a dated signature upon review. Currently, the Finance Department works directly with one or more agency employees from the relevant program/department. The reports are discussed and reviewed prior to submission. Anticipated Completion Date: December 31, 2024 Responsible Officials: Van Nelson and Joseph Collins

View Audit 340095

Finding 520332 (2022-003)

Material Weakness 2022

Talbot County Board of Education

GA

Cash Management Subrecipient Monitoring Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.305 § 200.511

FA 2022-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listi...

FA 2022-003 Improve Controls over Cash Management Compliance Requirement: Cash Management Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A200010 (Year: 2021) SO10A210010-21A (Year: 2022) Questioned Costs: None Identified Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: None Identified Repeat of Prior Year Finding: FA 2021-001, FA 2020-001, FA 2019-001, FA 2018-001, FA 2017-002, FA 2016-001, FA 2015-002, FA 2014-003 Description: The School District made cash drawdowns in excess of immediate cash needs for the Title I Grants to Local Educational Agencies and Elementary and School Emergency Relief Fund programs. Corrective Action Plans: District office has put procedures in action to make sure that all drawdowns are in line with expenditures. All draw down packets will be viewed and singed off by federal programs director. This packet will include detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Terrance H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

View Audit 340052

Finding 519921 (2022-004)

Significant Deficiency 2022

Gateway Community Health Centers, Inc.

NC

Internal Control / Segregation of Duties Significant Deficiency Special Tests & Provisions

Responsible Parties: Board of Directors (Dr. Althea Riddick, Chair). Corrected. The Board Members are currently compliance. Anticipated Date of Completion: Deadline: This is an ongoing requirement.

View Audit 339361

Finding 519918 (2022-001)

Material Weakness 2022

Gateway Community Health Centers, Inc.

NC

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.510

Responsible Parties: Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover) Gateway’s Management will utilize the implemented Matrix duties and responsibilities Grid to help monitor the documentation of required procedures and Standard Ope...

Responsible Parties: Chief Executive Officer (Rose Turner), Interim Chief Financial Officer (Dan Miles), Finance Director (Kelly Glover) Gateway’s Management will utilize the implemented Matrix duties and responsibilities Grid to help monitor the documentation of required procedures and Standard Operating Procedures approved by the Board of Directors. The health center will use the approved Financial Policies and Procedures Manual as its Standard Operating Procedures. The Health Center’s Management employs key management staff that reflects the size and composition of a health center. Ongoing evaluations will be used to monitor the qualifications of the staff. This Audit is a late submission, however with the submission a qualified Chief Financial Officer is in place and has the qualifications needed to assess and train staff accordingly and provide recommended changes to the department. This new Chief Financial Officer will serve as a technical resource to assist with the implementation of all the resolutions to the findings of the 2022 and 2023 audits

View Audit 339361

Finding 519364 (2022-005)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were b...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were based on gross charges and did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit. This process has been put in place and continues monthly during our month-end close meetings to ensure federal grant funds are being reported correctly. The Vice President of Finance, Eric Caldwell, will be the individual responsible for the corrective action plan.

View Audit 338246

Finding 519363 (2022-004)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate l...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27,2020, for the entire period of availability. The budget used in the calculation of lost revenue was not approved for the entire period of availability. The budget used to cover quarters in 2021 and 2022 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.

View Audit 338246

Finding 519000 (2022-002)

Significant Deficiency 2022

The Health Care Authority of the City of Huntsville

AL

Reporting Internal Control / Segregation of Duties § 200.303 § 200.512

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the ...

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the audit profession with a surge of new Single Audits to conduct that did not exist previously). In the Authority’s case, the situation was further complicated by the fact that we were changing external audit firms moving into this particular reporting period. By the time the incumbent audit firm had issued its Single Audit report for Fiscal 2021, and the successor audit firm could therefore begin the Fiscal 2022 Single Audit, it was already beyond the reporting deadline of March 31, 2023. The Authority will have the same finding for the Fiscal 2023 Single Audit, for the same reason. We are hoping to be able to work successfully with the successor audit firm in order to file our Single Audit for Fiscal 2024 timely on or before March 31, 2025 and also have timely filings thereafter.

View Audit 337494

Finding 518977 (2022-003)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management...

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

View Audit 337426

Finding 518975 (2022-001)

Significant Deficiency 2022

Thomas Wilbur Homestead, INC

RI

Internal Control / Segregation of Duties

United States Department of Housing and Urban Development Rhode Island Multifamily Program Center Thomas Wilbur Homestead respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Damiano, Burk & Nuttall, P.C. ...

United States Department of Housing and Urban Development Rhode Island Multifamily Program Center Thomas Wilbur Homestead respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period: For the year ended June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Establish and maintain documented monthly rent rolls and a current tenant security deposit liability summary into the month-end close process. Action Taken: Management agrees with the auditor’s finding and recommendation. If the United States Department of Housing and Urban Development has questions regarding this plan, please email Laura Jaworski at laura@thehouseofhopecdc.org.

View Audit 337424

Finding 518845 (2024-004)

Material Weakness 2022

Somali Community Link INC

OH

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.308 § 200.344

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any uno...

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any unobligated funds or, if applicable, seek authorization to retain the funds for use in other similar programs. This process will ensure proper financial management and compliance.

View Audit 337223 Questioned Costs: $1

Finding 518844 (2024-003)

Significant Deficiency 2022

Somali Community Link INC

OH

Reporting Program Income Internal Control / Segregation of Duties § 200.328

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provid...

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provided by senior management to ensure proper compliance and effective implementation.

View Audit 337223

Finding 518843 (2024-002)

Material Weakness 2022

Somali Community Link INC

OH

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. ...

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. A formal risk management policy will be developed and adopted within three months, with regular reviews scheduled thereafter to ensure its continued effectiveness and alignment with industry best practices.

View Audit 337223

Finding 518469 (2022-005)

Significant Deficiency 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Significant Deficiency Internal Control / Segregation of Duties

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 sing...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 single program audit shortly after the conclusion of the FY22 audit, with submission to the FAC as soon as completed. MACH will work with the audit firm to assure that all subsequent audits are completed timely.

View Audit 336928

Finding 518468 (2022-004)

Material Weakness 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.61

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Cu...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Currently, all grant documentation is assembled as transactions occur, and reimbursement requests are submitted to every grant source each month.

View Audit 336928

Finding 518446 (2022-001)

None 2022

Glens Falls Housing Authority

NY

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through their March 31, 2023 and March 31, 2024 fiscal year ends, and is making every effort to get their filings up to date by their March 31, 2025 year end due date.

View Audit 336840

Finding 518290 (2022-001)

Significant Deficiency 2022

Central Alabama Regional Planning and Development Commission

AL

Significant Deficiency Internal Control / Segregation of Duties § 200.302

Finding 2022-001: The Central Alabama Regional Planning & Development Commission (the Commission) will develop a grants manual or additional written policies to incorporate all the requirements of 2 CFR 200 and ensure compliance with grant requirements.

View Audit 336628

Finding 517839 (2022-001)

Significant Deficiency 2022

Unity Parenting & Counseling

IL

Internal Control / Segregation of Duties Reporting

• Stabilize Management: Focus on hiring and retaining experienced financial and management personnel to ensure consistent oversight and proper application of GAAP. • Strengtl,en Internal Controls: Implement more robust internal control procedures to prevent, detect, and correct financial reporting e...

• Stabilize Management: Focus on hiring and retaining experienced financial and management personnel to ensure consistent oversight and proper application of GAAP. • Strengtl,en Internal Controls: Implement more robust internal control procedures to prevent, detect, and correct financial reporting errors. This could include a formal review and approval process for significant transactions and an enhanced monitoring function during periods of transition. • Provide Training: Offer targeted GAAP and financial reporting training for new and existing management to ensure all financial transactions are recorded properly and in compliance with accounting standards. By implementing these measures, the organization can mitigate the risk of future misstatements, strengthen its financial reporting framework, and improve overall accuracy and compliance with GAAP.

View Audit 336007

Finding 517790 (2022-001)

Material Weakness 2022

Rural Water District No. 4, Neosho-Labette County, Ks

KS

Internal Control / Segregation of Duties

We will continue to have the Board of Directors review the financial activity of the entity. Due to the small size of the organization, it is not economically feasible to achieve a complete segregation of duties.

View Audit 335906

Finding 517353 (2022-006)

Material Weakness 2022

Laporte County

IN

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

FINDING 2022-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order t...

FINDING 2022-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the procurement and suspension and debarment compliance requirement. Prior to entering into subawards and covered transactions with Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, recipients are required to verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded. Upon inquiring of the County to determine its policies and procedures related to suspension and debarment requirements for the Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, the County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on all of the four vendors tested, that were paid with SLFRF Funds. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct this finding, we will begin doing a search on sam.gov to find out if a vendor has been suspended or disbarred. We will also add language to bid and/or contracts to require vendors to supply proof of being in good standing with the federal government. Anticipated Completion Date: The above plan of action will begin on November 21, 2024.

View Audit 335350

Corrective Action Plans

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