Corrective Action Plans

Finding 528954 (2021-004)

Material Weakness 2021

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2021-004 Reporting of Lost Revenue Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #910843...

Finding 2021-004 Reporting of Lost Revenue Federal Agency Name: Department of Health and Human Services Assistance Listing Number: #93.498 Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #910843135 Compliance Requirement: Reporting Finding Summary: The amounts reported for lost revenue did not agree to the supporting documentation provided. Corrective Action Plan: The District will confirm reporting requirements before submitting reporting data. Reporting data will be reviewed and reconciled to underlying supporting documentation. Responsible Individual: Paul Rogers, Chief Financial Officer

View Audit 346948

Finding 526797 (2021-010)

Material Weakness 2021

Muskogee County

OK

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

Assistance Listing Number 21.019 Lack of County-Wide Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to...

Assistance Listing Number 21.019 Lack of County-Wide Controls Over Major Federal Programs Coronavirus Relief Fund Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended.

View Audit 345861

Finding 526771 (2021-007)

Significant Deficiency 2021

Kittson County

MN

Reporting Internal Control / Segregation of Duties

Contact Person – Aimee Sugden, County Administrator Corrective Action Plan – The County will review policies and procedures over grant reporting. Completion Date – January 1, 2025

View Audit 345806

Finding 526705 (2021-004)

Material Weakness 2021

City of McKeesport

PA

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.412

CONDITION: For the calendar year 2021, the City of McKeesport submitted a listing to the Department of Treasury, of eligible expenses for the Coronavirus State and Local Fiscal Recovery Federal Funding. This listing contained the ShotSpotter as referenced in Finding 2021-004 which was already reimb...

CONDITION: For the calendar year 2021, the City of McKeesport submitted a listing to the Department of Treasury, of eligible expenses for the Coronavirus State and Local Fiscal Recovery Federal Funding. This listing contained the ShotSpotter as referenced in Finding 2021-004 which was already reimbursed to the City as part of the Community Development Block Grant (CDBG) Program by the Department of Housing and Urban Development. CRITERIA: In accordance with Section 2 CFR 200.412 of the Uniform Guidance, federal expenses are prohibited from being charged to more than one federal program. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review this eligible expense charged to the Coronavirus State and Local Fiscal Recovery Federal Funding Program, confirm that this is an expense that was already reimbursed by the Department of Housing and Urban Development for the benefit of the City’s CDBG Grant Program, and if so, consult with a representative from the Department of Treasury as to the procedure required to amend the quarterly report filings required to be filed with the Department of Treasury to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance. The timeframe for completion of this process is effective immediately.

View Audit 345703 Questioned Costs: $1

Finding 526704 (2021-002)

Material Weakness 2021

City of McKeesport

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting § 200.403

• CONDITION: During the calendar year 2021, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet f...

• CONDITION: During the calendar year 2021, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fashion similar to a checkbook used in personal finances, 2) recorded partially (expenses only with no revenue), or 3) not tracked at all. As these funds are not maintained using the City’s accounting software package, management does not have the ability to efficiently generate financial reports necessary to provide management with the proper fiscal oversight. This condition included the American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. However, it should be noted that City personnel were able to prepare spreadsheets to document which expenditures were utilized to prepare the necessary quarterly reporting requirements to the Department of Treasury. • CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include maintaining a formal general ledger system of accounting to track the activity of all ‘Funds’ maintained by the City. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the maintaining a formal general ledger system of accounting for all ‘Funds’ of the City. • MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will assess the current workload and expertise of the City’s business office personnel in an effort to determine a feasible timeframe to continue the process of creating a formal general ledger system of accounting for all City ‘Funds’ that are not already entered into the software accounting system. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City.

View Audit 345703

Finding 526697 (2021-001)

Material Weakness 2021

City of McKeesport

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting § 200.403

CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for t...

CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for these federal funds, independent of the aforementioned ‘Fund’ general ledgers sufficient to ascertain the revenues and expenditures of the federal programs. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include the reconciliation of all general ledger account balances to underlying supporting documentation monthly with independent oversight and approval as part of the process. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the applicable general ledgers of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review the recommended options as presented by the Audit Firm’s recommendation for feasibility considering current manpower, expertise, and budgetary constraints. In addition, the City plans to ensure that written procedures for all accounting functions are implemented, reviewed and updated as necessary with the objective of ensuring that all balance sheet account balances are supported by the underlying documentation available at the City. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the applicable general ledgers of the City.

View Audit 345703

Finding 526315 (2021-001)

Material Weakness 2021

Northwest Indian Community Development Center

MN

Internal Control / Segregation of Duties

Northwest Indian Community Development Center will correct this material weakness by establishing procedures to monitor revenue and support with donor restrictions to accuratly report net assets.

View Audit 345226

Finding 524400 (2021-007)

Material Weakness 2021

Quileute Tribal School

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: During the 2021 fiscal year there were superintendent vacancies. The School currently has a superintendent that is knowledgeable of this requirement. Implementation date: June 30, 2025

View Audit 343636

Finding 524399 (2021-006)

Material Weakness 2021

Quileute Tribal School

WA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...

Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff reports were not always documented or certified. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administrative positions are staffed. Training will be provided to staff responsible for Federal reporting. Implementation date: June 30, 2025

View Audit 343636

Finding 523531 (2021-001)

None 2021

National Council for Preservation Education

KY

Questioned Costs Eligibility Internal Control / Segregation of Duties

Recommendation: NCPE should have internal controls in place for the retention of federal program records. NCPE should also have procedures in place to allow for the review of an individual’s eligibility to receive a federal award. Response: NCPE’s Executive Committee hired a new manager in 2017 to ...

Recommendation: NCPE should have internal controls in place for the retention of federal program records. NCPE should also have procedures in place to allow for the review of an individual’s eligibility to receive a federal award. Response: NCPE’s Executive Committee hired a new manager in 2017 to create, track, and retain important records to comply with the terms and conditions of federal agreements. In addition to the application form completed by all interns, an award letter was introduced in 2019. The Award Letter is sent by the National Park Service (NPS) site supervisor to the successful candidate, with NCPE copied, to confirm their appointment and provide essential details about the internship like duration, rate of pay, location, paid time off, etc. This letter with the completed application form documents an intern's eligibility to participate in the program for a specific duration and rate of pay. For the current audit, applications or resumes were missing for 1 of the interns sampled and an award letter was missing for 1 intern. It was this lack of documentation that resulted in the questioned costs. Requiring a completed application has been a standard practice for several years but this wasn’t always the case when students applied directly to a site supervisor and not through the online application at PreserveNet (NCPE’s website for preservationists and preservation resources). Site supervisors are now regularly reminded about the program’s eligibility requirement, however, and management is confident that these interns, and all future interns, met the criteria for participation in the program. Nevertheless, in the future efforts will be intensified to improve record keeping. If NPS has any questions concerning these responses, please contact me or NCPE’s Treasurer, Doug Appler.

View Audit 342824 Questioned Costs: $1

Finding 522672 (2021-017)

Material Weakness 2021

Ottawa County

OK

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

The county will work to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.

View Audit 341985

Finding 522468 (2021-008)

Material Weakness 2021

Saint Anthony Health Ministries and Subsidiaries

IL

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

Finding: In accordance with 2 CFR 200 200.510(b), the auditee must prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502. The Corporation’s ...

Finding: In accordance with 2 CFR 200 200.510(b), the auditee must prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502. The Corporation’s Schedule of Expenditures of Federal Awards for the year ended June 30, 2021 was initially prepared without federal expenditures totaling $1,222,859 for the HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund, Assistance Listing number 93.461. Corrective Actions Taken or Planned: In July 2023, the Corporation has provided education and training to the staff regarding how to identify programs and costs that need to be reported on the annual SEFA. This includes a process to enhance internal controls around the timely identification of federal awards and the reconciliation of the SEFA to ensure that it is accurate and complete. Name of contact person responsible for corrective action: Rose Rosario, Director of Patient Financial Services.

View Audit 341736

Finding 522460 (2021-006)

Significant Deficiency 2021

Saint Anthony Health Ministries and Subsidiaries

IL

Reporting Internal Control / Segregation of Duties

Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entry prior to posting. The Corporat...

Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entry prior to posting. The Corporation’s system allowed the same individual to approve and post the same entry, and entries were posted with only one level of review. Corrective Actions Taken or Planned: A process has been established effective July 2022 where journal entries are reviewed by an individual with appropriate authority, different than the preparer of the journal entry. Jamie Mack, Vice President of Finance, will approve the journal entries of Caralton Brown, Assistant Controller, and Caralton Brown will review and approve the entries prepared by Jamie Mack and Michael Caddick, outside contractor. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.

View Audit 341736

Finding 522453 (2021-003)

Significant Deficiency 2021

Monticello Housing Authority

NY

HUD Housing Programs Eligibility Significant Deficiency

The Board of Commissioners has recently hired an Executive Director (ED) who will actively oversee all financial aspects of the agency. Additionally, it is the intent of the ED to hire a CPA as fee accountant, as soon as financially feasible, to keep finances current and accurate monthly. With the a...

The Board of Commissioners has recently hired an Executive Director (ED) who will actively oversee all financial aspects of the agency. Additionally, it is the intent of the ED to hire a CPA as fee accountant, as soon as financially feasible, to keep finances current and accurate monthly. With the added assistance of the existing bookkeeper, all financial systems should be operable and accurate going forward. Planned Implementation Date of Corrective Action: December 31, 2024 Person Responsible for Corrective Action: Pat Croslan, Executive Director

View Audit 341730

Finding 520683 (2021-003)

Material Weakness 2021

Russellville Hospital, Inc.

AL

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness § 200.303 § 200.512

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, 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 wi...

Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, 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: 01/31/25.

View Audit 340379

Finding 519947 (2021-007)

Material Weakness 2021

Health & Education Housing Service, INC

MA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

2021-007 - Special Tests and Provisions - Material Weakness Recommendation: Management should review the project budget to determine if nonessential costs can be cut or request a loan from the sponsor to ensure that the replacement reserve is funded in accordance with the terms of the regulatory ag...

2021-007 - Special Tests and Provisions - Material Weakness Recommendation: Management should review the project budget to determine if nonessential costs can be cut or request a loan from the sponsor to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement. Action Taken: The Managing Agent undertook an agency wide cost reduction beginning in March 2024, reducing project indirect costs by approximately 10-15%. Project direct costs cannot be reduced much further with most required services already being provided by city departments, and designated utility providers. The project has not had a budget increase since 2013, and while the project has a healthy replacement reserve balance in excess of $135k the project operating budget deficit is currently unable to fund those reserves without jeopardizing essential health and safety services. Management has sought and received multiple sponsor loans to address these shortfalls. The Management agent is presently prepared to submit for a required budget increase immediately following completion of all outstanding audits as required to secure the necessary rent increase.

View Audit 339373

Finding 519946 (2021-006)

Material Weakness 2021

Health & Education Housing Service, INC

MA

HUD Housing Programs Material Weakness Special Tests & Provisions § 200.625

2021-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan couldnot b...

2021-006 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain a HUD approved AFHMP and add the equal opportunity logo to marketing materials. Action Taken: Although it was believed that a HUD approved AFHMP was in place, documentation of this plan couldnot be located by all parties. The Managing Agent will take steps to obtain a new HUD approved AFHMP and include the equal opportunity logo to marketing materials.

View Audit 339373

Finding 519945 (2021-005)

Material Weakness 2021

Health & Education Housing Service, INC

MA

Internal Control / Segregation of Duties HUD Housing Programs Reporting

2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienc...

2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.

View Audit 339373

Finding 519944 (2021-004)

Material Weakness 2021

Health & Education Housing Service, INC

MA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. ...

2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.

View Audit 339373

Finding 519943 (2021-003)

Material Weakness 2021

Health & Education Housing Service, INC

MA

HUD Housing Programs Material Weakness Internal Control / Segregation of Duties

2021-003 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain fidelity bond coverage as required by HUD regulations. Action Taken: The Management Agent is not responsible, nor able to obtain fidelity coverage for this property. This is the responsibility of the...

2021-003 - Special Tests and Provisions - Material Weakness Recommendation: Management should obtain fidelity bond coverage as required by HUD regulations. Action Taken: The Management Agent is not responsible, nor able to obtain fidelity coverage for this property. This is the responsibility of the Sponsor. The Management agent will follow up with the sponsor to receive and report documentation when the appropriate coverage is in place.

View Audit 339373

Finding 519156 (2021-003)

Significant Deficiency 2021

22nd District Agricultural Association

CA

Questioned Costs Reporting Significant Deficiency

Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff....

Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff. Proposed Completion Date: December 31, 2022

View Audit 337708 Questioned Costs: $1

Finding 518974 (2021-001)

Significant Deficiency 2021

Thomas Wilbur Homestead, INC

RI

Internal Control / Segregation of Duties

FINDING 2022-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Ensure there is sufficient funds to make the required 12 deposits in order to bein compliance with its regulatory agreement. Action Taken: Management agrees with the auditor’s fin...

FINDING 2022-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Ensure there is sufficient funds to make the required 12 deposits in order to bein compliance with its regulatory agreement. 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 337423

Finding 518970 (2021-001)

Significant Deficiency 2021

George Galen Wheeler House INC

RI

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

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: Implement strict segregation of tenant security deposit funds, conduct regular reconciliations,...

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: Implement strict segregation of tenant security deposit funds, conduct regular reconciliations, and establish regular record-keeping practices. Action Taken: Management agrees with the auditor's finding and recommendation.

View Audit 337418

Finding 518350 (2021-002)

Material Weakness 2021

The Center: Resources for Teaching and Learning

IL

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.14

Audit Recommendation: The Organization should search federal database to ensure vendors paid using federal funds are not suspended or disbarred. Planned Corrective Actions: The Organization will review its procurement procedures to ensure they include performing and documenting the appropriate searc...

Audit Recommendation: The Organization should search federal database to ensure vendors paid using federal funds are not suspended or disbarred. Planned Corrective Actions: The Organization will review its procurement procedures to ensure they include performing and documenting the appropriate searches. The Organization accepts the recommendation. Anticipated Completion Date: June 30, 2025 Contact Person: Helen Gates, Accounting

View Audit 336734

Finding 518349 (2021-001)

Material Weakness 2021

The Center: Resources for Teaching and Learning

IL

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Audit Recommendation: Existing timesheet reconciliation procedures should be revised. The Organization should reconcile employee timesheets to amounts allocated to the grants on, at minimum, a quarterly basis, and ideally, on a monthly basis prior to the submission of vouchers or funding requests. P...

Audit Recommendation: Existing timesheet reconciliation procedures should be revised. The Organization should reconcile employee timesheets to amounts allocated to the grants on, at minimum, a quarterly basis, and ideally, on a monthly basis prior to the submission of vouchers or funding requests. Planned Corrective Actions: The Organization is reviewing and updating its procedures to reconcile the timesheets to the voucher requests monthly prior to submitting the voucher requests. The Organization accepts the recommendation. Anticipated Completion Date: December 31, 2024 Contact Person: Helen Gates, Accounting

View Audit 336734

Corrective Action Plans

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