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Corrective Action Plans

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Finding 1235975 (2022-004)
Material Weakness 2022
Metro Area Continuum of Care for the Homeless
NE
Internal Control / Segregation of Duties Subrecipient Monitoring Reporting
Finding Reference Number 2022: Reporting Description of Finding: Management was unable to provide several required monthly and quarterly Emergency Rental Assistance Program reports requested during the audit and, for reports that were available, could not provide sufficient supporting documentation ...
Finding Reference Number 2022: Reporting Description of Finding: Management was unable to provide several required monthly and quarterly Emergency Rental Assistance Program reports requested during the audit and, for reports that were available, could not provide sufficient supporting documentation to substantiate certain reported amounts. Statement of Concurrence or Nonconcurrence: Threshold CoC concurs with the finding. Corrective Action: Management will strengthen controls over grant reporting by maintaining a reporting calendar with due dates and assigned owners; requiring completion, retention, and timely submission of all required monthly and quarterly reports; and retaining sufficient supporting documentation and reconciliations for all amounts reported to the grantor. A supervisory review will be documented before reports are submitted. This is similar to prior-year finding 2021-002. The corrective action above adds formal report tracking, retention, supporting documentation, and documented supervisory review to address the repeated issue. Name of Contact Person: Jason Feldhaus, Executive Director, jason@thresholdcoc.org Projected Completion Date: December 31, 2026 Questioned Costs: None.
View Audit 411573
Finding 1235934 (2022-002)
Material Weakness 2022
Southeastern Regional Medical Center
NC
Subrecipient Monitoring Cash Management Reporting § 200.512
2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 3...
2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 30, 2022, was not filed with the Federal Audit Clearinghouse on or before the deadline of March 31, 2023. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.
View Audit 411536
Finding 1229753 (2022-004)
Material Weakness 2022
GROW FOOD dba Viva Farms
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.303 § 200.329
Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To implement a procedure that documents the Executive Director's review and approval of the annual REEports, such as retaining evidence of approval through a signed report or email correspondence. In add...
Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To implement a procedure that documents the Executive Director's review and approval of the annual REEports, such as retaining evidence of approval through a signed report or email correspondence. In addition, management should establish controls and provide training to help ensure reports are reviewed, approved, and submitted timely in accordance with applicable requirements Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a documented review and approval process for annual REEports prior to submission. Each year, the completed REEport will be sent to the Executive Director for review, and the Executive Director's approval will be documented via email prior to submission. This email approval will be retained as evidence of review, along with the submitted report. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026
View Audit 410987
Finding 1229752 (2022-002)
Material Weakness 2022
GROW FOOD dba Viva Farms
WA
Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303
Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To provide additional training to employees and supervisors responsible for timesheet preparation and approval to reinforce compliance with established timesheet policies and approval controls. Explanati...
Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To provide additional training to employees and supervisors responsible for timesheet preparation and approval to reinforce compliance with established timesheet policies and approval controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will provide additional training to both employees responsible for preparing timesheets and to supervisors responsible for reviewing and approving them. This training will cover accurate and timely recording of time worked, including proper allocation of time to federal grant programs, and will reinforce Viva Farms' existing timesheet policies and supervisor approval requirements before timesheets are submitted to payroll.. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026
View Audit 410987
Finding 1228667 (2022-002)
Material Weakness 2022
Housing Authority of the City of Tulsa
OK
HUD Housing Programs Internal Control / Segregation of Duties
Housing Choice Voucher Program – ALN #14.871 Recommendation: We recommend that the Authority review their process for scheduling HQS inspections to ensure that they are done timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in respo...
Housing Choice Voucher Program – ALN #14.871 Recommendation: We recommend that the Authority review their process for scheduling HQS inspections to ensure that they are done timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has strengthened its process for scheduling and monitoring HQS inspections to improve timely completion of required inspections. Management implemented enhanced tracking tools, including monthly inspection due-date reports and workflow alerts, to identify inspections approaching deadline. The Compliance team now performs monthly reconciliation reviews of inspection schedules and completed inspections, and Housing Choice Voucher staff have received refresher training on HQS inspection requirements, scheduling procedures, and documentation standards. Name(s) of the contact person(s) responsible for corrective action: Teresa Wolfe, Assistant Vice President Planned completion date for corrective action plan: December 31, 2026
View Audit 410330
Finding 1228639 (2022-006)
Material Weakness 2022
TOWN OF SPRING LAKE
NC
Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.334
SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Caroli...
SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Carolina League of Municipalities to provide additional training to the Town ‘s staff. Proposed Completion Date: December 31, 2026.
View Audit 410277
Finding 1228543 (2022-001)
Material Weakness 2022
THE LIGHTHOUSE, INC.
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410164
Finding 1228538 (2022-001)
Material Weakness 2022
LEEWARD KOKUA HOUSING INC
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410162
Finding 1228533 (2022-002)
Material Weakness 2022
WELLNESS HOUSE INC
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410160
Finding 1228530 (2022-004)
Material Weakness 2022
HONOLULU HOUSE, INC.
HI
HUD Housing Programs Internal Control / Segregation of Duties
The tenant was not able to provide a forwarding address when she moved out because she was unsure of the address and promised to call the project. After repeated attempts to obtain the information, the tenant finally reached out to provide the information and a check was cut and mailed right away. P...
The tenant was not able to provide a forwarding address when she moved out because she was unsure of the address and promised to call the project. After repeated attempts to obtain the information, the tenant finally reached out to provide the information and a check was cut and mailed right away. Project staff were reminded of the importance of obtaining the required information no later than the day of move-out so a refund can be given to the tenant. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410158
Finding 1228527 (2022-001)
Material Weakness 2022
HONOLULU HOUSE, INC.
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410158
Finding 1228522 (2022-001)
Material Weakness 2022
THE NEWHOUSE INC
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected C...
Planned Corrective Action: The audited financial statements for FY2022 will be finalized before the end of the month, and shortly thereafter, the single audit reporting package will be transmitted to FAC. Name of Contact Person: Melby Albano, MHK HUD Housing Manager, and Greg Payton, CEO Projected Completion Date: 12/31/2024
View Audit 410156
Finding 1227478 (2022-003)
Material Weakness 2022
Apsaalooke Nation Housing Authority
MT
Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties
2022-003. Finding: Special Tests and Provisions - Cash Collateralization (Compliance; Internal Controls Over Compliance (2021-003) Material Weakness The corrective actions implemented in FY 2022 Extraordinary circumstances beyond ANNA control. ANNA received large deposits from Treasury without notic...
2022-003. Finding: Special Tests and Provisions - Cash Collateralization (Compliance; Internal Controls Over Compliance (2021-003) Material Weakness The corrective actions implemented in FY 2022 Extraordinary circumstances beyond ANNA control. ANNA received large deposits from Treasury without notice and did not have the proper cash collateralization in place. ANNA has since made agreements with the bank.
View Audit 409514
Finding 1227166 (2022-001)
Material Weakness 2022
County of Rockingham
NH
Reporting Significant Deficiency Internal Control / Segregation of Duties
Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required...
Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required to be reported under Federal Assistance Listing Number (ALN) 93.498- COVID-19 - Provider Relief Fund. This resulted in an incomplete reporting of federal expenditures under the appropriate ALN. To address this issue, the County will implement the following corrective actions: 1. Training and Guidance: Staff responsible for SEF A preparation will receive additional training regarding federal reporting requirements, including how to align HRSA filings with SEFA reporting and the appropriate identification of Assistance Listing Numbers. 2. Improved Coordination: The County will establish closer coordination between the departments submitting reports to federal agencies (such as HRSA) and those compiling the SEFA to ensure consistency and completeness. 3. Periodic Reconciliations: The County will implement periodic reconciliations of its general ledger and departmental grant records against federal reporting requirements throughout the fiscal year, rather than waiting until year-end. This will support more timely and accurate SEFA preparation. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance
View Audit 409335
Finding 1227064 (2022-007)
Material Weakness 2022
TOWN OF DOVER, MASSACHUSETTS
MA
Internal Control / Segregation of Duties Reporting Significant Deficiency
Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes i...
Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes in the Town Accountant's office and the new Town Accountant will work to ensure general ledger data is reported accurately as well as review prepared reports thoroughly prior to submission. Planned Implementation Date of Corrective Action: Present Day Person Responsible for Corrective Action: Christopher Costello, Assistant Town Administrator/Finance Director
View Audit 409253
Finding 1225863 (2022-001)
Material Weakness 2022
SOUTH SHORE REGIONAL SCHOOL DISTRICT
MA
Internal Control / Segregation of Duties
Internal controls to be strengthened to ensure that Federal awards are properly identified.
Internal controls to be strengthened to ensure that Federal awards are properly identified.
View Audit 408558
Finding 1225676 (2022-007)
Material Weakness 2022
Quileute Tribal School
WA
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303
Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to...
Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent NOTE: In addition, Quileute Tribal School has engaged an independent CPA firm to assist with account reconciliations and audit readiness to help ensure that financial information is complete, accurate, and properly reported. Implementation Date: July 30, 2026
View Audit 408537
Finding 1225675 (2022-006)
Material Weakness 2022
Quileute Tribal School
WA
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303
Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requireme...
Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requirement and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent Implementation Date: July 30, 2026
View Audit 408537
Finding 1224464 (2022-005)
Material Weakness 2022
Monticello Housing Authority
NY
Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs
2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD ...
2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD and Housing Authority policies, in addition to staffing changes, to ensure that this finding will be cleared by the subsequent fiscal year audit. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director
View Audit 407735
Finding 1224365 (2022-003)
Material Weakness 2022
Russellville Hospital, Inc.
AL
Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.512
The hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 09/30/2026
The hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 09/30/2026
View Audit 407672
Finding 1224364 (2022-004)
Material Weakness 2022
Russellville Hospital, Inc.
AL
Questioned Costs Material Weakness Reporting
The loan was acquired from previous owners of the hospital and was obtained by current owners at the time of purchase. This year was the first year the program was required to be audited. We are actively working to ensure this condition is met by ensuring the reserve fund is met, the debt service co...
The loan was acquired from previous owners of the hospital and was obtained by current owners at the time of purchase. This year was the first year the program was required to be audited. We are actively working to ensure this condition is met by ensuring the reserve fund is met, the debt service coverage ratio of at least 1.0 is obtained, and audited financials available to USDA annually. Anticipated completion date: 09/30/2026
View Audit 407672
Finding 1224304 (2022-001)
Material Weakness 2022
City of Stover
MO
Reporting Internal Control / Segregation of Duties
Corrective Action: Procedures will be implemented to reflect the modified cash basis of accounting, which is the method used for the budget, so that the City Clerk makes the necessary adjusting journal entries. Proposed completion date: The Board will implement the above procedure immediately.
Corrective Action: Procedures will be implemented to reflect the modified cash basis of accounting, which is the method used for the budget, so that the City Clerk makes the necessary adjusting journal entries. Proposed completion date: The Board will implement the above procedure immediately.
View Audit 407592
Finding 1224134 (2022-004)
Material Weakness 2022
STRESS & TRAUMA TREATMENT CENTER INC
IL
Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles
Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly dis...
Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly distribute salary and benefit costs for employees who work in whole or in part on grant program activity in accordance with the Uniform Guidance. This includes having the documentation reviewed and formally approved by a supervisor. Anticipated Date of Completion: December 31, 2026 Name of Contact Person: Matt Buckman, Executive Director
View Audit 407517
Finding 1224132 (2022-003)
Material Weakness 2022
STRESS & TRAUMA TREATMENT CENTER INC
IL
Internal Control / Segregation of Duties
Condition: The Organization has a lack of segregation of duties over its receipts and disbursements as one individual is responsible for virtually all duties. Plan: Management is working with its staff and Board to implement the recommendations above to the extent possible. Anticipated Date of Compl...
Condition: The Organization has a lack of segregation of duties over its receipts and disbursements as one individual is responsible for virtually all duties. Plan: Management is working with its staff and Board to implement the recommendations above to the extent possible. Anticipated Date of Completion: December 31, 2026 Name of Contact Person: Matt Buckman, Executive Director
View Audit 407517
Finding 1223980 (2022-002)
Material Weakness 2022
NEW YORK MORTGAGE COALITION, INC.
NY
Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303
Management will review its policies and procedures to ensure that all quarterly reports and the supporting documentation used to prepare the reports are retained for audit purposes. All the reports will be reviewed and approved by someone other than the preparer prior to submission.
Management will review its policies and procedures to ensure that all quarterly reports and the supporting documentation used to prepare the reports are retained for audit purposes. All the reports will be reviewed and approved by someone other than the preparer prior to submission.
View Audit 407388
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