Corrective Action Plans

Finding 1179948 (2021-003)

Material Weakness 2021

ADAMS COUNTY PUBLIC HOSPITAL DISTRICT #3 D/B/A OTHELLO COMMUNITY HOSPITAL

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.

View Audit 392296

Finding 1177790 (2021-006)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Internal Control / Segregation of Duties

2021-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...

2021-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 391158

Finding 1177785 (2021-001)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...

2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.

View Audit 391158

Finding 1176174 (2021-003)

Material Weakness 2021

City of Chester

PA

Eligibility Material Weakness Reporting

The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklist...

The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklists and reconciliations being prepared and reviewed. Retroactive review processes are underway regarding 2022 and 2023 years to be audited.

View Audit 389991

Finding 1171351 (2021-002)

Material Weakness 2021

Ekentucky Advanced Manufacturing Institute INC

KY

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022...

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022 by January 3 1, 2026. The information for audits of the subsequent years' financial statements will be submitted within 30 days of the completion of the prior year audit. The organization expects to be current on the audits and filings by December 31, 2027.

View Audit 384645

Finding 1171348 (2021-001)

Material Weakness 2021

Ekentucky Advanced Manufacturing Institute INC

KY

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

We concur with the recommendation, and the organization is actively working to get the audits current. The info1mation to do the audit of the financial statements for 2022 will be submitted by January 31, 2026. The information for audits of the subsequent years' financial statements will be submitte...

We concur with the recommendation, and the organization is actively working to get the audits current. The info1mation to do the audit of the financial statements for 2022 will be submitted by January 31, 2026. The information for audits of the subsequent years' financial statements will be submitted within 30 days of the completion of the prior year audit The organization expects to be cmTent on the audits by December 31, 2027.

View Audit 384645

Finding 1169705 (2021-002)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Period of Performance § 200.303

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in fo...

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1169704 (2021-001)

Material Weakness 2021

Pittsburg County

OK

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

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be requ...

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1167846 (2021-002)

Material Weakness 2021

Northern Marianas Housing Corporation

FM

Subrecipient Monitoring Eligibility HUD Housing Programs

Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind...

Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind them of their insurance status. Moving forward, we will be sending out demand notices to those listed accounts that were affected. Corrective Action for Condition 2: This loan account is noted and being monitored to ensure that future policy coverage accurately reflects the loan amount as cited. Corrective Action for Condition 3: Property insurance coverage for HP-367, HNC-403 and HNC-534 were subsequently renewed on 4/28/2022, 8/30/2022 and 11/16/2021, respectively. MCD will ensure that these account policies are being monitored for subsequent updates and renewals. Corrective Action for Condition 4: MCD will ensure moving forward that these accounts are carefully monitored and in compliance with required annual recertifications. Corrective Action for Condition 5: The two loan accounts, HL-178 and HL-196 were underwritten twenty years ago; therefore, corrective action regarding these two accounts would not be applicable. MCD verified and confirmed that the required document was not in the respective files. It is also possible the document was received but might have been misplaced or got lost in the process. Corrective Action for Condition 6: MCD will be unable to perform any corrective action to obtain such document as account is nearly twenty years old. It should be noted that the account has been referred for collection. Corrective Action for Condition 7: MCD will be unable to perform any corrective action to obtain such document as nearly twenty years has lapsed (possible misfiling or misplaced).

View Audit 379196

Finding 1166193 (2021-001)

Material Weakness 2021

Bemidji Regional Interdistrict Council No. 998

MN

Internal Control / Segregation of Duties

Management’s Response – Corrective Action Plan 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding A. Review current segregation of duties among existing staff within administrative office that have any assigned...

Management’s Response – Corrective Action Plan 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding A. Review current segregation of duties among existing staff within administrative office that have any assigned duties relative to the financial operations of the Council. B. Determine appropriate approval and oversight of all journal entries. Continue to require dual signatures on all checks and approval of all expenditures monthly by the Board. Consider all correspondence received relative to finance (bank statements, financial statements, other) be received by the Executive Director’s office unopened upon receipt. Executive Director will review journal entries and bank (financial) reconciliations and sign off monthly. 3. Official Responsible for Ensuring CAP Implementation Brenda Story, Executive Director 4. Planned Completion of CAP Reviewed annually. 5. Plan to Monitor Completion of CAP Executive Director will review any changes in duties on an annual basis.

View Audit 377082

Finding 1165510 (2021-001)

Material Weakness 2021

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 376224

Finding 1165037 (2021-009)

Material Weakness 2021

Pima Council on Aging

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler...

Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA has instituted an internal review and approval process for the Schedule of Expenditures of Federal Awards (SEFA), which now requires sign-off by the Finance Director prior to submission to the auditors.  The third-party accounting firm prepared and reconciled the SEFA in collaboration with internal staff  Technical hires are being made to ensure continued compliance and review capacity during year-end closing. Completion Date: July 31, 2025

View Audit 375125

Finding 1165036 (2021-008)

Material Weakness 2021

Pima Council on Aging

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Directo...

Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA, with the assistance of DES, has created a grant compliance tracking system.  PCOA has also implemented oversight procedures to ensure all federal reports are submitted accurately and on time.  The Finance Director will assist in structuring these controls around the training program and finance staff.  The Finance Director oversees this process, and their capacity to do so has been strengthened through targeted hiring of experienced finance professionals.

View Audit 375125

Finding 1165029 (2021-001)

Material Weakness 2021

Pima Council on Aging

AZ

Material Weakness Equipment & Real Property Management Internal Control / Segregation of Duties

Finding Number 2021-001: Material Adjustments to Financial Statements, July 1, 2020 through June 30,2021. Statement of Condition: PCOA made adjustments to the financial statements that resulted in material changes to the reported financial position. PCOA personnel responsible for enacting corrective...

Finding Number 2021-001: Material Adjustments to Financial Statements, July 1, 2020 through June 30,2021. Statement of Condition: PCOA made adjustments to the financial statements that resulted in material changes to the reported financial position. PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: 1. PCOA acknowledges the material adjustments identified and has retained a third-party accounting firm to remediate the deficiencies. A formal month-end closing schedule has been implemented to ensure timely reconciliations and accurate financial reporting. All balance sheet accounts, including receivables, fixed assets, intercompany balances, and accruals, are now reconciled monthly. 2. PCOA has implemented new billing procedures to ensure revenue and related expenses are recorded in accordance with the matching principle and GAAP. These procedures were developed with support from the third-party accounting firm to ensure grant-related transactions are accurately recorded within the proper accounting period. 3. A new Finance Director has been hired to oversee the finance team and began their tenure on July 21,2025. Additional staff with strong technical accounting skills are being recruited, at the recommendation and direction of the third-party firm, to stabilize operations and maintain GAAP compliance. 4. A memo was drafted and sent out to PCOA staff, notifying the team of the change in procedures, in addition to an explanation of the impact of accrual accounting and GAAP compliance. Completion Date: June 30, 2025

View Audit 375125

Finding 1164266 (2021-005)

Material Weakness 2021

Puerto Rico Emergency Management and Disasters Bureau

PR

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302 § 200.328

Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports...

Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports include federal and recipient share, drawdown activity, and unliquidated obligations, designate responsible personnel for review and approval prior to filing with evidence of submission retained, and provide staff training on federal reporting requirements under 2 CFR 200.327–200.329 to strengthen compliance and accuracy in financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

View Audit 373614

Finding 1164240 (2021-004)

Material Weakness 2021

Portsmouth Redevelopment and Housing Authority

VA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreemen...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend the Authority review its internal controls over allowable costs to ensure all documentation is maintained at the time expenses are paid. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority is prioritizing completion of outstanding audits to ensure records can be located promptly when requested. All invoices will continue to require proper approval signatures prior to payment, and payment authorization will serve as an additional layer of verification to confirm compliance with internal control procedures. This instance involved only one of forty (40) accounts payable items that was not available in the document imaging system at the time of review so it needed to be recreated by printing off the invoice and it was paid online. The payment would have had to be pre-approved by CFO prior to payment. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling, CFO Planned completion date for corrective action plan: 12/1/25

View Audit 373527 Questioned Costs: $1

Finding 1163085 (2021-002)

Material Weakness 2021

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately

View Audit 372661

Finding 1163015 (2021-008)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1163014 (2021-007)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1163010 (2021-003)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Subrecipient Monitoring Material Weakness Matching / Level of Effort / Earmarking § 200.501 § 200.512 § 200.514

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding. The Chief Financial Officer in collaboration with the Finance Associate and the Financial Consultant will set a calendar at the end fof the fiscal year to ensure timely closeout of the books that wil...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding. The Chief Financial Officer in collaboration with the Finance Associate and the Financial Consultant will set a calendar at the end fof the fiscal year to ensure timely closeout of the books that will allow ample time to engage and complete the audit prior to the deadline for the FAC filing.

View Audit 372604

Finding 1162314 (2021-003)

Material Weakness 2021

Levee Road Water Association, Inc.

KY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

The Association concurs with the recommendation. The Association has implemented a new procedure to ensure that any future reporting compliance requirements related to the expenditure of federal funds are completed on a timely basis.

View Audit 372132

Finding 1162168 (2021-007)

Material Weakness 2021

JOHN C. FREMONT HEALTHCARE DISTRICT

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit...

JCFHD experienced substantial leadership and staff turnover in key financial roles over multiple years, including the CEO, CFO, and finance team. As a result, the individuals who originally prepared the lost revenues calculation were no longer employed at the facility when the Uniform Guidance audit was conducted. This led to challenges in locating complete supporting documentation for the original calculation, resulting in additional calculations being necessary. Under new leadership, JCFHD has prioritized the development and implementation of robust policies and procedures to ensure that all relevant financial documentation is readily accessible for future Uniform Guidance audits. These measures are intended to strengthen internal controls and improve audit readiness. Corrective Action: 1. Provide additional training to finance staff on GAAP financial reporting and disclosure requirements to strengthen internal review and oversight. 2. Implement a documented review process for financial statements and footnotes prepared by external auditors, including CFO and Board-level approval prior to issuance. Completion Date: Within 120 days.

View Audit 371977

Finding 1161064 (2021-004)

Material Weakness 2021

Coal County Healthcare Authority

OK

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

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultan...

Condition - Expenditures reported to HRSA were not in accordance with Pub. L. No. 116-136, 134 Stat. 563 Plan of Corrective Action Much research was performed by the Authority's leadership to identify guidance from HRSA including reviewing FAQs, Fact Sheets, consulting attorneys, auditors, consultants and other parties. The complexity of the reporting requirements, including changing FAQ's and our inability to gain a definite approval of the use of our funds, resulted in the Authority filing the its submission based on the best available information at the time. The Authority's position is that the Provider Relief Funds were appropriately expensed using additional expenses and lost revenues not initially submitted to the portal. The Authority will continue to monitor the guidance for use of funds provided by HRSA and will strive to appropriately utilize all funds in the future. The Authority will review the most recently distributed Provider Relief Fund FAQ's which provide details on requirements related to the program Contact person: Chris Martin, CEO cmartin@ccghospital.com (580)927-2327 Expected implementation:2024 - 2025

View Audit 371035 Questioned Costs: $1

Finding 1159994 (2021-004)

Material Weakness 2021

Native Village of Tyonek

AK

Special Tests & Provisions Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Management will be working with a consultant to update their written policies and procedures to be in compliance with the requirements of the Uniform Guidance.

View Audit 370455

Finding 576268 (2021-011)

Material Weakness 2021

Community Homeless Solutions

CA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Internal Control / Segregation of Duties

The agency will revise its procurement policy to comply with Federal requirements and implement it consistently across the organization

View Audit 366162

Corrective Action Plans

Filters