Corrective Action Plans

Finding 485611 (2024-002)

Significant Deficiency 2024

Fulton County Community Unit School District No. 3

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.

View Audit 318383

Finding 485406 (2024-002)

None 2024

Lincoln Christian University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.

View Audit 318153

Finding 485172 (2024-002)

Significant Deficiency 2024

Regis University

CO

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.

View Audit 317977

Finding 479384 (2024-001)

None 2024

Casa Barranquitas, Inc. Hud Project No. 056-Eh-346-Wah-L8

PR

Questioned Costs Cash Management HUD Housing Programs § 200.305

We agree. The reimbursement has been processed in the Voucher for the month of August 2024. Procedures have been established improving the reviewing and monitoring process in order to detect and help to identify errors before vouchers processed.

View Audit 315891 Questioned Costs: $1

Finding 477896 (2024-001)

Significant Deficiency 2024

Clinica Campesina Family Health Services

CO

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.

View Audit 314530

Finding 1166594 (2023-001)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.

View Audit 377585

Finding 1166456 (2023-001)

Material Weakness 2023

Eastern Kentucky PRIDE, Inc.

KY

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

Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.

View Audit 377479

Finding 1166325 (2023-009)

Material Weakness 2023

Dorchester County, Maryland

MD

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

The County will implement procedures to ensure the review and approval of the monthly report is documented.

View Audit 377392

Finding 1166324 (2023-008)

Material Weakness 2023

Dorchester County, Maryland

MD

Eligibility Matching / Level of Effort / Earmarking § 200.303

The County will implement procedures to ensure the approval process is documented.

View Audit 377392

Finding 1163089 (2023-002)

Material Weakness 2023

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2023-002: 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 2023-002: 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 372663

Finding 1162834 (2023-002)

Material Weakness 2023

United Somali Women of Maine

ME

Reporting Matching / Level of Effort / Earmarking § 200.512

After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, r...

After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. The Outsourced CFO will ensure that the Organization submits timely single audit data collection and reporting package to the Federal Audit Clearinghouse. 22

View Audit 372500

Finding 1162833 (2023-001)

Material Weakness 2023

United Somali Women of Maine

ME

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

The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With...

The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. These changes were necessary to ensure proper U.S. GAAP practices were in place. These updates include accurately accruing accounts payable and accounts receivable, to ensure revenue and expenses are recognized in the proper period. We have also implemented a proper review process of the financial statements and any adjustments that are required to finalize them. The Organization believes it have fully addressed and corrected all procedures that led to this finding.

View Audit 372500

Finding 1162403 (2023-002)

Material Weakness 2023

Avita Health System

OH

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

Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...

Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023

View Audit 372185

Finding 1161858 (2023-003)

Material Weakness 2023

Merrill Pioneer Community Hospital, Inc

IA

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

We have implemented procedures to ensure we are in compliance with all reporting requirements. Individuals have been assigned to be responsible for the preparation and submission of reports. The Board has implemented procedures to monitor the compliance and communicate the procedures to new members.

View Audit 371778

Finding 1161830 (2023-002)

Material Weakness 2023

City of Ceres

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Planned Correction Action: Management will file the audited financial statements for the year ended June 30, 2023, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ER...

Planned Correction Action: Management will file the audited financial statements for the year ended June 30, 2023, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ERP system implementation, and delays in reconciling certain major balance sheet accounts. To address these issues, the City engaged an external financial consultant to assist in completing outstanding bank reconciliations and restoring timely financial reporting. Management is also implementing additional corrective measures, including reprioritizing workloads, enhancing oversight of monthly close activities, and establishing standardized reconciliation checklists for all major balance sheet accounts. Management anticipates that this finding will extend through the Fiscal Year 2024, Fiscal Year 2025, and possibly Fiscal Year 2026 financial statement reporting cycles, with full resolution expected in Fiscal Year 2027.

View Audit 371755

Finding 1161624 (2023-006)

Material Weakness 2023

Arizona Immigrant and Refugee Services, INC

AZ

Questioned Costs Subrecipient Monitoring Matching / Level of Effort / Earmarking

AIRS management will improve procedures and add additional controls to record sufficient matching amounts in order to satisfy the matching requirements of the federal award program, including proper documentation and processing of in-kind items that are included in the matching fund internal reports...

AIRS management will improve procedures and add additional controls to record sufficient matching amounts in order to satisfy the matching requirements of the federal award program, including proper documentation and processing of in-kind items that are included in the matching fund internal reports so they are supported and valued as required under Uniform Guidance.

View Audit 371485 Questioned Costs: $1

Finding 1161623 (2023-005)

Material Weakness 2023

Arizona Immigrant and Refugee Services, INC

AZ

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.318 § 200.327

AIRS management has started the process of creating new and updated policies and procedures related to financial reporting, activities, including written procurement standards, written standards of conflict of interest and others as required under Uniform Guidance.

View Audit 371485

Finding 1161443 (2023-002)

Material Weakness 2023

Collegeville Borough

PA

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.302

Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.

View Audit 371314

Finding 1161283 (2023-003)

Material Weakness 2023

Morgan County

OH

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.202 § 200.208 § 200.301 § 200.328

The Morgan County Economic Development Office acknowledges status reports submitted by the required due date for the CDBG program.

View Audit 371205

Finding 1161188 (2023-002)

Material Weakness 2023

Clare|matrix

CA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Responsible Official's Response: In addition to our response to Finding 2023-001, we have hired a new Director of Human Resources as of December 2023. Most of the issues regarding record retention revolve around HR documentation. As such our new Director will have a significant impact on this proces...

Responsible Official's Response: In addition to our response to Finding 2023-001, we have hired a new Director of Human Resources as of December 2023. Most of the issues regarding record retention revolve around HR documentation. As such our new Director will have a significant impact on this process going forward more so in FY 24-25 rather than FY 23-24. We have taken steps to insure the Human Resources records are audit ready and we have implemented our own internal review process to insure record readiness.

View Audit 371186 Questioned Costs: $1

Finding 1161060 (2023-001)

Material Weakness 2023

King David Community Center of Atlanta, Inc.

GA

Matching / Level of Effort / Earmarking

King David Community Center of Atlanta will implement policies and procedures to ensure the timely filing of the data collection form and the Annual Audited Financial Statement to the Federal Audit Clearinghouse.

View Audit 371028

Finding 1161045 (2023-003)

Material Weakness 2023

Center for International Private Enterprise, Inc.

DC

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.512

Views of Responsible Officials: Management has made significant changes in staffing and processes to ensure future Single Audit reports are completed within the required timeframes.

View Audit 371017

Finding 1161011 (2023-002)

Material Weakness 2023

Center for International Private Enterprise, Inc.

DC

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.318

Views of Responsible Officials: Management is implementing a new oversight and monitoring program that trains third-party contractors, qualifies them to do business with CIPE, and terminates the relationship for non-compliance with the terms, conditions and specifications of their contracts. This pr...

Views of Responsible Officials: Management is implementing a new oversight and monitoring program that trains third-party contractors, qualifies them to do business with CIPE, and terminates the relationship for non-compliance with the terms, conditions and specifications of their contracts. This program will be managed by the Legal and Compliance Department with significant support from the Grants Management department. Refined contractual language with third party contractors will require the submission of accurate and timely reports before any payments are made to contractors. In 2026, CIPE will institute an internal process staffed by multi-functional teams to perform site visits and audits, in line with the requirements of the new oversight and monitoring program.

View Audit 371017

Finding 1160443 (2023-005)

Material Weakness 2023

Housing Authority of the City of Daytona Beach, Florida

FL

Eligibility HUD Housing Programs Material Weakness

2023-005 Eligibility – Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Material Weakness in Internal Control, Material Noncompliance This is a repeat finding of 2022-004, reported as a Material Weakness and Material Noncompliance from June 30, 2022 (initially occurred as Finding ...

2023-005 Eligibility – Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Material Weakness in Internal Control, Material Noncompliance This is a repeat finding of 2022-004, reported as a Material Weakness and Material Noncompliance from June 30, 2022 (initially occurred as Finding 2021-002, Material Weakness and Material Noncompliance) Condition: Out of a total tenant population of approximately 269 tenant files, 25 files were selected for testing. Exceptions were noted as follows: • 4 tenant files where the 214 Affidavit was not in the file or was incorrectly completed (2 files for missing 214 affidavits and 2 files where boxes were not checked to indicate adults were signing for dependents). • 5 tenant files where the tenant’s personal declaration form was missing for the time period tested. • 2 tenant files where the Form 9886 were missing for the time period tested. • 10 tenant files where there were income issues (including income calculation errors or missing support or missing Forms 50058). • 7 tenant files had deduction issues (several for deductions that were taken twice for food stamp income that was “excluded” and then deducted again, incorrect utility allowances, incorrect child care costs). • 1 tenant file where the Form 50058 was missing so unable to determine if recertification date was correct. • 4 tenant files with missing birth certificates • 1 tenant file where the tenant’s date of birth on the 50058 form did not match the tenant’s birth certificate. • 5 tenant files with missing social security cards. • 1 tenant file where the adult tenants did not sign the lease agreement. • 5 tenant files with missing EIVs. Auditor’s Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: As was also instituted for HCV participant files, the Authority has instituted a checklist sheet that will occupy the front interior of all tenant files. This checklist will contain every document that is required to be placed in the tenant file. The Authority has and will affirm the use of its procedures, and continue to implement procedures to ensure all tenant files are maintained in accordance with policies and procedures. Additionally: • All noted deficiencies will be corrected and cured. • The Authority has also taken steps to stabilize staff by hiring a Property Manager and an Occupancy Specialist that will support the Public Housing Department. • The Authority has implemented a 100% quality control review of all participant files. Task will be completed by an outside specialized compliance consulting company. The consulting company will report initial findings to the Authority and deficiencies will be cured. Thereby reducing any additional findings with tenant files. • Repeated noted errors will be reported to the Senior Property Manager and additional hand's-on training regarding deficient items will be completed as necessary.

View Audit 370860

Finding 1160396 (2023-005)

Material Weakness 2023

California Asian Pacific Chamber of Commerce

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.334

Finding Reference Number: 2023-005 Description of Finding: Unable to provide supporting documentation for one expense sample. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges that...

Finding Reference Number: 2023-005 Description of Finding: Unable to provide supporting documentation for one expense sample. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges that this finding is a deficiency in its procedures. The Director of Finance is reviewing the Chamber’s record retention policies and internal controls to ensure that they are in compliance with 2 CFR § 200.334, and will recommend and implement improvements as needed. Staff responsible for federal grants will receive training on documentation and retention requirements. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: September 2025

View Audit 370809

Corrective Action Plans

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