Corrective Action Plans

Finding 42704 (2022-001)

Material Weakness 2022

IL

Internal Control / Segregation of Duties Subrecipient Monitoring

Corrective Action Plan To the extent possible, monitoring of monthly financial results and compliance information will continue in the County Courthouse offices and the County Health Department. Anticipated Completion Date The County is not in a financial position to hire additional employees. The...

Corrective Action Plan To the extent possible, monitoring of monthly financial results and compliance information will continue in the County Courthouse offices and the County Health Department. Anticipated Completion Date The County is not in a financial position to hire additional employees. The increased monitoring has already begun. Responsible Parties Kenneth Walker, Mason County Board Chairman 125 North Plum Havana, Illinois 62644 (309)543-3359 Cari Meeker, County Treasurer 125 North Plum Havana, Illinois 62644 (309)543-3359 Curt Jibben, County Health Department Administrator 1002 East Laurel Ave. Havana, Illinois 62644 (309)210-0110

View Audit 43953

Finding 42701 (2022-004)

Significant Deficiency 2022

City of Thibodaux, Louisiana

LA

Internal Control / Segregation of Duties

The City of Thibodaux Finance Director, Jessica Hebert, and the Assistant Finance Director, Joycelyn Gros, will work on reconciliation and review processes for the annual coronavirus funding reporting process by coming up with a procedure to document the reconciliation of the report to the general l...

The City of Thibodaux Finance Director, Jessica Hebert, and the Assistant Finance Director, Joycelyn Gros, will work on reconciliation and review processes for the annual coronavirus funding reporting process by coming up with a procedure to document the reconciliation of the report to the general ledger and to document the review of the reconciliation as well as review of the report before submission. The Finance Director, Jessica Hebert, will print the report before submission so that the Assistant Finance Director, Joycelyn Gros, can review and mark on the grant reimbursement review form. This process will become effective with the next submission that is due April 30, 2024.

View Audit 43947

Finding 42699 (2022-002)

Material Weakness 2022

City of Thibodaux, Louisiana

LA

Cash Management Reporting Internal Control / Segregation of Duties

The City of Thibodaux Finance Director, Jessica Hebert, and/or the Assistant Finance Director, Joycelyn Gros, will work with the Emergency Preparedness Director, Jacques Thibodeaux, on e-mail communications for reminders as well as to show documentation that the reports are filed timely. After the E...

The City of Thibodaux Finance Director, Jessica Hebert, and/or the Assistant Finance Director, Joycelyn Gros, will work with the Emergency Preparedness Director, Jacques Thibodeaux, on e-mail communications for reminders as well as to show documentation that the reports are filed timely. After the Emergency Preparedness Director, Jacques Thibodeaux, has documents ready to submit, the Finance Director, Jessica Hebert, and/or Assistant Finance Director, Joycelyn Gros, will review to make sure it matches General Ledger and will show documentation of review by using the grant reconciliation review form. This will be implemented immediately.

View Audit 43947

Finding 42690 (2022-001)

Significant Deficiency 2022

St Patrick Manor INC

OH

Questioned Costs Internal Control / Segregation of Duties Reporting

CORRECTIVE ACTION PLAN September 29, 2022 U.S. Department of Housing and Urban Development St. Patrick Manor, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: HW&Co. 23240 Chagrin Blvd, Suite ...

CORRECTIVE ACTION PLAN September 29, 2022 U.S. Department of Housing and Urban Development St. Patrick Manor, Inc. respectively submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: HW&Co. 23240 Chagrin Blvd, Suite 700 Cleveland, OH 44122-5450 Audit period: July 1, 2021 through June 30, 2022 The finding from the June 30, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT AND FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-001 Supportive Housing for the Elderly ? CFDA #14.157 Recommendation: St. Patrick Manor, Inc. should deposit underfunded amount into the replacement reserve account. Action Taken: St. Patrick Manor, Inc. agrees with the recommendation. Management has corrected all items and completed the deposit into the replacement reserve account on September 29, 2022. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Fred Berry at 330-384-1555

View Audit 39298 Questioned Costs: $1

Finding 42678 (2022-001)

Significant Deficiency 2022

Florida Living Options, INC

IL

Reporting Internal Control / Segregation of Duties § 200.303

Identifying Number: 2022-001 Corrective Action Taken or Planned: Ron Wilson is responsible to ensure corrective actions are taken. Management reviews the reported grant expenditures. Management believes this review process to be adequate.

View Audit 54111

Finding 42674 (2022-002)

Material Weakness 2022

Fall River Housing Authority

RI

HUD Housing Programs Material Weakness Reporting

INTRODUCTION: The last three years have been challenging to the FRHA on many fronts. There were vacancies in several key executive management positions, the Executive Director abruptly retired, and particularly the Director of Finance position had seen three people serve in that role. There was also...

INTRODUCTION: The last three years have been challenging to the FRHA on many fronts. There were vacancies in several key executive management positions, the Executive Director abruptly retired, and particularly the Director of Finance position had seen three people serve in that role. There was also the COVID-19 pandemic, where key staff people were absent, or working remotely as labor laws were relaxed. Emergency Contracts were issued with many of the formal bidding policies and procedures being forgiven, making it more difficult on internal controls over financial reporting. REMEDY: Stability has been restored with the hiring of a new Executive Director and Deputy Executive Director along with the Director of Finance position. The FRHA is working closely with HUD and DHCD officials, in setting up automated reminders of all Financial Reporting Deliverables to all key personnel. The Executive Director is also meeting bi-monthly with all FRHA Financial team members to review monthly financial requirements. The Executive Director is further forging a stronger professional relationship with the FRHA Fee Accountants and Auditors to establish better communication on all Financial Controls.

View Audit 53305

Finding 42672 (2022-002)

Significant Deficiency 2022

Network Housing 92, Inc.

OH

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits ...

Finding Number: 2022-002 Condition: The Organization failed to make the required reserve for replacements deposits in the current fiscal year. Planned Corrective Action: Management agrees with the finding as reported. Management has instituted procedural changes to ensure that all required deposits are made monthly. Additionally, management has taken steps to deposit all delinquent deposits. Contact person responsible for corrective action: Paul Anderson, CFO Anticipated Completion Date: 12/31/2023

View Audit 53087

Finding 42662 (2022-001)

Significant Deficiency 2022

Hias & Council Migration Service of Philadelphia

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of State U.S. Refugee Admissions Program ? ALN 19.510 Audit Finding: 2022-001 ...

U.S. Department of State U.S. Refugee Admissions Program ? ALN 19.510 Audit Finding: 2022-001 Planned Corrective Action: Management agrees with the finding and has taken corrective action by purchasing and implementing software which will track the employee?s actual time spent.

View Audit 53266

Finding 42652 (2022-001)

Significant Deficiency 2022

Halls Ferry Manor, INC

MO

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

Recommendation: We recommend the Project review controls to include timely review of year-end financials and surplus cash calculation so surplus cash is deposited timely.

View Audit 51388

Finding 42651 (2022-001)

Significant Deficiency 2022

Cabot Performing Arts Center, INC

MA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Management has been making updates to its policies and procedures throughout 2022 to be in full compliance with the Uniform Guidance. This exercise is anticipated to be complete by the end of the fiscal year.

View Audit 51333

Finding 42647 (2022-002)

Material Weakness 2022

D H, Incorporated

OR

HUD Housing Programs Eligibility Material Weakness

Management?s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Finance Director/ShelterCare 2. The corrective action planned: a. Pinehurst Management is the management agent overseeing property through 4/30/202...

Management?s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Finance Director/ShelterCare 2. The corrective action planned: a. Pinehurst Management is the management agent overseeing property through 4/30/2023. A new management agent will be identified to take over the property after 4/30/2023. b. Ensure that the new managing agent employs an onsite manager with HUD compliance experience. c. Currently prioritizing recertifications by oldest first. d. Monthly review of TRACS reports to ensure recertifications are being completed in a timely manner. 3. The anticipated completion date: a. New processes will be implemented by 5/1/2023.

View Audit 50186

Finding 42646 (2022-001)

Material Weakness 2022

St. Mary's Residence, Inc.

MN

Internal Control / Segregation of Duties

2022-001 Audit adjustments Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disa...

2022-001 Audit adjustments Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers (management agent) will establish a review process to ensure that all necessary adjustments are made to the financial statements prior to the audit process. 3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for insuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2023 audit. 5. Plan to Monitor Completion of CAP Julie Baruch (board chair) and Sara Wohlers will be monitoring this plan.

View Audit 49389

Finding 42638 (2022-001)

Material Weakness 2022

Mighty Fortress Manor

MN

Internal Control / Segregation of Duties

2022-001 Audit adjustments Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disa...

2022-001 Audit adjustments Auditor Recommendation Recommendation: We recommend that the Organization verifies all necessary adjustments are made to the financial statements prior to the audit process. Corrective Action Plan (CAP) 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Sara Wohlers (management agent) will establish a review process to ensure that all necessary adjustments are made to the financial statements prior to the audit process. 3. Official Responsible for Insuring CAP Sara Wohlers is the official responsible for insuring corrective action of the deficiency. 4. Planned Completion Date for CAP This plan will be implemented for the September 30, 2023 audit. 5. Plan to Monitor Completion of CAP John Frank (board chair) and Sara Wohlers will be monitoring this plan.

View Audit 49018

Finding 42632 (2022-001)

Significant Deficiency 2022

Village Cooperative of Alexandria

MN

Internal Control / Segregation of Duties Significant Deficiency

The Board of Directors is and will remain involved in the financial affairs of the Cooperative.

View Audit 47257

Finding 42617 (2022-001)

Significant Deficiency 2022

Rosamond Hills, Inc.

CA

Reporting Internal Control / Segregation of Duties

Name of Auditee: Rosamond Hills, Inc RD Case No. 04-015-647929361 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2022 through December 31, 2022 CAP prepared by: Name: Gretchen Winfrey Position: Treasurer Email: winfrey3314@yahoo.com Finding 2022-001 Commen...

Name of Auditee: Rosamond Hills, Inc RD Case No. 04-015-647929361 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2022 through December 31, 2022 CAP prepared by: Name: Gretchen Winfrey Position: Treasurer Email: winfrey3314@yahoo.com Finding 2022-001 Comments: Management agrees with the finding. Actions: Management will implement internal controls and monitor the reserve for replacement account to ensure the reserve for replacement is funded each year in accordance with USDA-RD regulations.

View Audit 46004

Finding 42615 (2022-001)

Significant Deficiency 2022

Elizabeth James Senior Housing

WA

HUD Housing Programs Special Tests & Provisions Cash Management

Contact Person(s): Hilary Prinz, Accounting Manager, 206-687-4080 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Due to turnover of staff the residual receipt payment in the amount of $83,818 for 2021 audit was not ...

Contact Person(s): Hilary Prinz, Accounting Manager, 206-687-4080 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Due to turnover of staff the residual receipt payment in the amount of $83,818 for 2021 audit was not made in 2022. Corrective action planned: The entire finance team has been familiarized with Elizabeth James residual receipt requirement. If there is staff turnover in the future everyone on the team is aware of the requirement. A repeating event reminder has been entered into the property accountant?s calendar, the property asset manager?s calendar, and the finance calendar causing multiple alerts to multiple people within the organization going forward. Anticipated completion date: The 2021 residual receipt deposit requirement in the amount of $83,818.00 was paid via check on March 20, 2023. Repeating calendar events have been completed as of March 29, 2023.

View Audit 44080

Finding 42612 (2022-001)

Material Weakness 2022

Scripps Health and Affiliates

CA

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

Finding 2022-001: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late FY22 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: ? Revised the current timekeeping policy to clarify employee and mana...

Finding 2022-001: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late FY22 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: ? Revised the current timekeeping policy to clarify employee and manager responsibilities ? Modified failure to comply provisions ? Deployed educational programs for both management and staff ? Reviewed/improved Kronos Time and Attendance system automated notifications ? Made training resources available to management and staff via our Scripps intranet site Leadership monitors policy compliance by individual employee and manager via systemwide reporting on a biweekly basis. Contact person: Eric Cole Expected Completion Date: Completed ? September 2022

View Audit 40148

Finding 42611 (2022-002)

Material Weakness 2022

Scripps Health and Affiliates

CA

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

Finding 2022-002: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late FY22 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: ? Revised the current timekeeping policy to clarify employee and mana...

Finding 2022-002: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late FY22 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: ? Revised the current timekeeping policy to clarify employee and manager responsibilities ? Modified failure to comply provisions ? Deployed educational programs for both management and staff ? Reviewed/improved Kronos Time and Attendance system automated notifications ? Made training resources available to management and staff via our Scripps intranet site Leadership monitors policy compliance by individual employee and manager via systemwide reporting on a biweekly basis. Contact person: Eric Cole Expected Completion Date: Completed ? September 2022

View Audit 40148

Finding 42592 (2022-006)

Significant Deficiency 2022

Saint Mary's College of California

CA

Internal Control / Segregation of Duties Student Financial Aid Reporting § 200.303

Corrective Action Plan for the Year Ended June 30, 2022 Finding 2022-006: Significant Deficiency ? Control Environment Condition/Context: It was noted during the audit, that there were gaps in the internal control structure of the College, that was no longer adequate to ensure compliance with fede...

Corrective Action Plan for the Year Ended June 30, 2022 Finding 2022-006: Significant Deficiency ? Control Environment Condition/Context: It was noted during the audit, that there were gaps in the internal control structure of the College, that was no longer adequate to ensure compliance with federal regulations and compliance requirements. Action Taken: The staffing changes in the Business Office and the Financial Aid office resulted in learning curves for the new employees. Both offices have started projects to document procedures so that when turnover occurs, there is a blueprint in place to assist the new employees. SMC will also review the internal controls in place for federal reporting to determine how they can be strengthened. Name(s) of Contact Person Responsible for Corrective Action: Nicole Yu, AVP/Controller and Joseph Gilchrist, Interim Financial Aid Director Anticipated Completion dates: Documenting procedures is on ongoing project. Revised internal controls for federal reporting will be in place by June 30, 2023.

View Audit 38194

Finding 42589 (2022-002)

Significant Deficiency 2022

Memorial Regional Health

CO

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2022-002 United States Department of Agriculture CFDA 10.766 Community Facilities Loans and Grants Cluster Special Tests and Provisions Significant Deficiency in Internal Controls Over Compliance Finding Summary: There was no evidence retained that the Hospital?s recalculates debt covenants as requi...

2022-002 United States Department of Agriculture CFDA 10.766 Community Facilities Loans and Grants Cluster Special Tests and Provisions Significant Deficiency in Internal Controls Over Compliance Finding Summary: There was no evidence retained that the Hospital?s recalculates debt covenants as required or performs any review of one of the two financial debt covenant calculations. Responsible Individuals: Brittany Johnson, CFO Corrective Action Plan: Management will implement a control process which includes periodic calulation and review of all financial debt covenants. Anticipated Completion Date: Action taken and completed on 5/31/23

View Audit 39522

Finding 42583 (2022-001)

Material Weakness 2022

United Way of Greater Charlottesville

VA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

PAYROLL DOCUMENTATION: The Organization concurs with the finding. The Organization has determined it is now staffed appropriately given the resources available and will continue to look for new opportunities to address these findings.

View Audit 39313

Finding 42581 (2022-001)

Significant Deficiency 2022

Mineral Springs School District

AR

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

Implemented proper controls where the Title I Coordinator,Wendy, Reed, the General Business Manager, Frankie Tollett, and Bookkeeper, Myra Brand review all program expenditures to ensure they are allowable expenditures. We have contacted DESE for assistance on correcting this. When: July 1, 2023

View Audit 38287 Questioned Costs: $1

Finding 42578 (2022-004)

Significant Deficiency 2022

Owen-Withee School District

WI

Equipment & Real Property Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.313

2022-004 Equipment & Property Management - ESSER Recommendation: We recommend the District should consider having another individual, besides the one Performing the data entry, perform a review after the data is entered into the software. Explanation of disagreement with audit finding: There is no d...

2022-004 Equipment & Property Management - ESSER Recommendation: We recommend the District should consider having another individual, besides the one Performing the data entry, perform a review after the data is entered into the software. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The district will have either the superintendent or district bookkeeper look over the entries that were performed during the school year for the fixed assets. Name(s) of the contact person(s) responsible for corrective action: Stacy Rasmussen Planned completion date for corrective action plan: Ongoing.

View Audit 39681

Finding 42570 (2022-001)

Significant Deficiency 2022

Willow Creek Community Church, Inc.

IL

Internal Control / Segregation of Duties Reporting

2022-001. The Church does not maintain dual control over certain funds and the duties of certain employees are incompatible. Repeat Finding: This finding was a component of number 2021-001 in the prior year Schedule of Findings and Questions Costs ? Federal Programs. Condition: 1) The storage of f...

2022-001. The Church does not maintain dual control over certain funds and the duties of certain employees are incompatible. Repeat Finding: This finding was a component of number 2021-001 in the prior year Schedule of Findings and Questions Costs ? Federal Programs. Condition: 1) The storage of funds in the safes located in the accounts receivable office at the South Barrington campus are not under dual control (we noted that multiple individuals have individual access to the safes). These safes hold unprocessed funds received in the mail and other funds received during the week. 2) The accounts receivable manager, accounts receivable specialist, and the donations coordinator at the South Barrington campus are responsible for handling incoming cash receipts, can individually access funds stored in the safes in the accounts receivable office, and are responsible for modifying donor records. Recommendation: 1) We recommend that the Church take additional steps to implement appropriate dual control procedures, such as by modifying the safes located in the accounts receivable office at the South Barrington campus to require two individuals to access their contents. It is our understanding that subsequent to December 31, 2022, the Church began utilizing a dual control safe to hold mail and other funds received during the week at the South Barrington campus. 2) We recommend the Church take steps to address the incompatibility of the duties assigned to the accounts receivable manager, the accounts receivable specialist, and the donations coordinator at the South Barrington campus in order to reduce the risk of undetected misappropriation. Views of Responsible Officials and Planned Corrective Action: 1) A dual control drop safe requiring two separate keys was installed to accept mail deliveries (to safeguard mail that may contain checks) and other funds received during the week at the South Barrington campus. 2) Church processes around the handling of donations and cash require two people at all times and include several mitigating controls. The count room is also closely monitored by several security cameras. The installation of a dual control safe (per above) adds an additional level of security and resolves concerns about misappropriations going undetected. Installation of the safe is complete and is fully functional. It is our understanding that the accompanying processes have been found to be acceptable but will be further reviewed during the 2023 audit.

View Audit 40157

Finding 42566 (2022-003)

Material Weakness 2022

Ahoskie Housing Authority

NC

Eligibility HUD Housing Programs Material Weakness

Corrective Action Plan For the year ended June 30, 2022 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Finding 2022-002 Name of Contact Person: Tarsha Dudley, Executive Director Corrective Action: We will review our intake and rec...

Corrective Action Plan For the year ended June 30, 2022 Section II - Financial Statement Findings Section III - Federal Award Findings and Questioned Costs Finding 2022-002 Name of Contact Person: Tarsha Dudley, Executive Director Corrective Action: We will review our intake and recertification procedures. We will also review our tenant file monitoring procedures. Proposed Completion Date: Immediately

View Audit 38348

Corrective Action Plans

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