Corrective Action Plans

Finding 1241219 (2022-002)

Material Weakness 2022

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-002 - Reporting - Significant Deficiency in Internal Control over Compliance and Other Matter Name and Contact Person: Desiree Rock, Tribal Administrator Corrective Action Plan: Management will ensure that federal grant reporting is filed timely by the reporting deadlines. Proposed Completion D...

2022-002 - Reporting - Significant Deficiency in Internal Control over Compliance and Other Matter Name and Contact Person: Desiree Rock, Tribal Administrator Corrective Action Plan: Management will ensure that federal grant reporting is filed timely by the reporting deadlines. Proposed Completion Date: December 31, 2026

View Audit 415307

Finding 1241199 (2022-002)

Material Weakness 2022

SIERRA SVING GRACE HMELESS PRJ

CA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Refer to the Attached Management's Formal Response and Corrective Action Plan.

View Audit 415297

Finding 1241198 (2022-001)

Material Weakness 2022

SIERRA SVING GRACE HMELESS PRJ

CA

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

Refer to the Attached Management's Formal Response and Corrective Action Plan.

View Audit 415297

Finding 1240571 (2022-004)

Material Weakness 2022

NUNAKAUYARMIUT TRIBE

AK

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2022-004 Lack of Internal Control over Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strengthened its gra...

Finding 2022-004 Lack of Internal Control over Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strengthened its grant and financial reporting procedures. The Tribe will maintain a centralized schedule of federal awards and required reporting deadlines identifying the awarding agency, award number, period of performance, reporting frequency, report type, due date, responsible staff member, and submission status. Finance, Administration, and applicable program personnel will coordinate to ensure that financial and program information necessary to complete required reports is available before applicable deadlines. Financial reports will be reconciled to the Tribe's accounting records before submission. Copies of submitted reports, supporting documentation, and evidence of submission will be retained in the applicable grant file. Management will periodically review the reporting schedule to identify upcoming or outstanding requirements and take corrective action when necessary. Proposed Completion Date: September 30, 2026.

View Audit 414987

Finding 1240565 (2022-007)

Material Weakness 2022

NUNAKAUYARMIUT TRIBE

AK

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

Finding 2022-007 Lack of Internal Control Over Special Test and Provisions – Environmental Review Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strengthened procedures t...

Finding 2022-007 Lack of Internal Control Over Special Test and Provisions – Environmental Review Name of Contact Person: Dora Mathew, Tribal executive Director Mary Carl, Tribal Financial Officer Corrective Action Plan: Nunakauyarmiut Tribe concurs with the finding and has strengthened procedures to ensure required environmental reviews are completed and documented before federally funded activities proceed when environmental review requirements apply. For HUD-funded activities, the Tribe will identify the applicable environmental review requirements at the beginning of the project and maintain the Environmental Review Record and related supporting documentation in the grant file. No choice-limiting action, commitment of funds, or project activity requiring environmental clearance will proceed until the required environmental review process and applicable HUD approvals or releases have been completed. Administration, Finance, Housing, and project personnel will coordinate before procurement, contracting, construction, or other project commitments to verify environmental clearance status. Documentation of exemptions, categorical exclusions, environmental reviews, public notices, requests for release of funds, HUD approvals, and related records will be retained as applicable. Staff responsible for HUD projects will seek HUD technical assistance or training when needed to ensure continued compliance. Proposed Completion Date: September 30, 2026.

View Audit 414987

Finding 1240204 (2022-005)

Material Weakness 2022

Ekentucky Advanced Manufacturing Institute INC

KY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.317 § 200.318 § 200.327

The Institute will adopt written procurement policies and procedures that conform to the Uniform Guidance procurement standards, present them to the Board of Directors for approval, and train the personnel responsible for procurement on their use. Anticipated completion date: December 31, 2026. Resp...

The Institute will adopt written procurement policies and procedures that conform to the Uniform Guidance procurement standards, present them to the Board of Directors for approval, and train the personnel responsible for procurement on their use. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

View Audit 414796

Finding 1240203 (2022-004)

Material Weakness 2022

Ekentucky Advanced Manufacturing Institute INC

KY

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.339 § 200.501 § 200.512 § 200.520

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit an...

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

View Audit 414796

Finding 1240085 (2022-001)

Material Weakness 2022

Public Buildings Authority

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Implement closing calendar, compliance tracking, SEFA standarization and supervisory review.

View Audit 414703

Finding 1240034 (2022-008)

Material Weakness 2022

Akiachak Native Community

AK

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

Finding 2022-008 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Management will strengthen internal controls over payroll and review personnel files for adequate p...

Finding 2022-008 Lack of Internal Controls Over Activities Allowed or Unallowed and Allowable Costs/Costs Principles Name of Contact Person: Noelle George, Tribal Administrator Corrective Action Plan: Management will strengthen internal controls over payroll and review personnel files for adequate pay rate documentation. Proposed Completion Date: October 31, 2026.

View Audit 414656

Finding 1238448 (2022-003)

Material Weakness 2022

BREAKTHRU HOUSE, INC

GA

Reporting Internal Control / Segregation of Duties Eligibility § 200.512

Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that i...

Organization’s response: The Organization concurs with the finding and will implement our recommendation immediately. Corrective Action Plan: The Organization will implement enhanced internal controls over compliance with federal award requirements by establishing a formal compliance calendar that includes all key reporting deadlines, including audit and FAC submission requirements. Responsibilities for each compliance requirement will be clearly assigned to specific personnel. Management will monitor the calendar regularly to ensure all deadlines are met. Additionally, the Organization will implement a review process to ensure submissions are accurate, complete, and timely. Contact: BreNita Jackson, Executive Director

View Audit 413318

Finding 1236263 (2022-006)

Material Weakness 2022

Community Homeless Solutions

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Improve payroll allocations ensuring accuracy of actual time worked. Also, documentation should reflect work performed accurately.

View Audit 411850

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

Corrective Action Plans

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