Corrective Action Plans

Finding 404724 (2023-005)

Significant Deficiency 2023

College Unbound

RI

Student Financial Aid Cash Management Reporting

Finding number: 2023-005 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: As found, the College has policies and procedures in place to report the disbursement records to the Department of Educat...

Finding number: 2023-005 Federal agency: U.S. Department of Education Programs: Federal Pell Grants Assistance listing #: 84.063 Award year: 2023 Corrective Action Plan: As found, the College has policies and procedures in place to report the disbursement records to the Department of Education through the COD system within the required fifteen calendar days. This singular Pell update was caught by the College while performing the year end Pell closeout. The record was corrected prior to the audit, but past the required timeframe. The College's corrective plan for this is to perform monthly Pell reconciliation at the same time as the required monthly Direct Loan reconciliation. By doing monthly reconciliation, we will catch potential corrections within the required timeframe. We enacted this practice in advance of the FY24 year. Timeline for Implementation of Corrective Action Plan: This was corrected in advance of the start of FY24. We will continue to review as noted. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

View Audit 311103

Finding 404722 (2023-004)

Material Weakness 2023

College Unbound

RI

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking

Finding number: 2023-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2...

Finding number: 2023-004 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.063 and 84.268 Award year: 2023 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Bursar’s scope of work is to work with Financial Aid to ensure that ledgers are correct. Reconciliation reports are also reviewed monthly to ensure accuracy and resolve discrepancies timely. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, Vice President for Institutional and Student Sustainability/CFO

View Audit 311103

Finding 404698 (2023-002)

Significant Deficiency 2023

Ke Ola Mamo

HI

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

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. I...

Ref No. 2023-002 SIGNIFICANT DEFICIENCYI It was noted one instance out of forty that the employee timesheet did not agree with the payroll register. The hours on the timesheet were 45, while the hours on the payroll register were 48 hours. This resulted in an overcharge of $159 to the program. It was also noted one out of seventy-one timesheets were not approved by the supervisor. Recommendation: Ke Ola Mamo should exercise greater care in reviewing timesheets and data entered into the payroll system to ensure that only allowable costs are charged to the program. Action Taken: Ke Ola Mamo was in the process of implementing an on-line payroll processing system during Fiscal Year 2023. The implementation was completed during Fiscal Year 2023. This process minimizes potential clerical errors as employees input the hours they work directly into the on-line payroll system, with employees’ supervisors and the Human Resources Specialist approving prior to the payroll being processed.

View Audit 311070

Finding 404541 (2023-002)

Significant Deficiency 2023

Shoshone County

ID

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.319 § 200.327

2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be ...

2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be followed and dated to be turned into the auditor's office to be approved prior to purchases as to see all steps have been completed of the procurement policy prior of purchasing items on any federal award. All items by County Auditor will be processed and looked at again prior to a check written.

View Audit 311060 Questioned Costs: $1

Finding 404438 (2023-002)

Significant Deficiency 2023

Economic Development Corporation

MO

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2023-002: Assistance #11.307 - Economic Adjustment Assistance - Revolving Loan Fund, U.S. Department of Commerce, Economic Development Administration, Award No. 05-39-01879 (Significant Deficiency) (Repeat Finding 2022-002) Condition: Reports submitted during the year were not submitted wi...

Finding 2023-002: Assistance #11.307 - Economic Adjustment Assistance - Revolving Loan Fund, U.S. Department of Commerce, Economic Development Administration, Award No. 05-39-01879 (Significant Deficiency) (Repeat Finding 2022-002) Condition: Reports submitted during the year were not submitted within the deadline and the review process was not documented. Criteria: All Economic Development Administration (EDA) Revolving Loan Fund (RLF) recipients must submit in electronic format Form ED-209 through EDA’s Revolving Loan Fund Management System (RLFMS) semi-annually based on the entity’s fiscal year-end and submitted within 30 calendar days. Corrective Action Plan: The EDC Loan Corporation ED-209 Reports will be reviewed and submitted by the required 30 calendar days following the entity's fiscal year-end due date. EDCLC will submit the ED-209 Reports 5-10 days prior to the reporting due date, allowing for any correction response submission. Contact Person: Debra Davis Anticipated Completion Date: 11/30/2024

View Audit 311038

Finding 404223 (2023-005)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: ...

Corrective Action Plan: Atrium Health CMHA management will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: Management will complete the corrective action plan by the end of 2024.

View Audit 310986

Finding 404222 (2023-004)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete...

Corrective Action Plan: Atrium Health CMHA management will address the current year finding either through system modifications to allow for electronic saving of the applicable notifications or by implementing a manual process to retain them. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404221 (2023-003)

Material Weakness 2023

Atrium Health, Inc.

NC

Student Financial Aid Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completene...

Corrective Action Plan: Atrium Health CMHA management will address the gap in SFA transactional review and approval internal controls, arising due to the SFA program size and limited number of subject matter experts, by implementing mitigating controls and policies to ensure accuracy and completeness of transactions. Proposed Completion Date: Management will complete the corrective action plan by October 2024.

View Audit 310986

Finding 404220 (2023-002)

Material Weakness 2023

Atrium Health, Inc.

NC

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

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...

Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.

View Audit 310986

Finding 404187 (2023-002)

Significant Deficiency 2023

National Federal of Families for Children's Mental Health

MD

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.

View Audit 310958

Finding 404185 (2023-001)

Significant Deficiency 2023

National Federal of Families for Children's Mental Health

MD

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Action Taken: NFFCMH now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY2023 Audit

View Audit 310958

Finding 404157 (2023-003)

Material Weakness 2023

City of Jacksonville

FL

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Questioned Costs § 200.212 § 200.303 § 200.318 § 200.332 § 200.514

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404156 (2023-002)

Material Weakness 2023

City of Jacksonville

FL

Allowable Costs / Cost Principles Questioned Costs Special Tests & Provisions § 200.303 § 200.330

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

View Audit 310950

Finding 404104 (2023-003)

Significant Deficiency 2023

Rochester Housing Authority

NY

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a)...

Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - HQS inspections of Shelter Plus Care properties will be performed on an annual basis. (c) Planned implementation date of corrective action - Completed by September 30, 2024.

View Audit 310889

Finding 404102 (2023-001)

Material Weakness 2023

City of Groveland, Florida

FL

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking § 200.303

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by som...

The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by someone else in the City independent of the report preparation. This review will focus on ensuring the reports are complete, accurate, and fully compliant with all stipulated grant requirements.

View Audit 310883

Finding 404007 (2023-003)

Significant Deficiency 2023

Great Lakes Inter-Tribal Council Inc.

WI

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report...

Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2024

View Audit 310846

Finding 403911 (2023-001)

Significant Deficiency 2023

Tallassee City Board of Education

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent ...

Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2024 claim.

View Audit 310807 Questioned Costs: $1

Finding 403856 (2023-005)

Significant Deficiency 2023

Palm Beach County Housing Authority

FL

HUD Housing Programs Reporting Significant Deficiency

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will implement processes to ensure that HUD 50058 submissions are uploaded in accordance with HUD regulations. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024

View Audit 310743

Finding 403813 (2023-004)

Significant Deficiency 2023

Institute for Sustainable Communities, Affiliate and Subsidiary

VT

Questioned Costs Cash Management Period of Performance § 200.303

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated...

Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.

View Audit 310730

Finding 403810 (2023-003)

Material Weakness 2023

Seeley Lake School District

MT

Subrecipient Monitoring Matching / Level of Effort / Earmarking

FINDING 2023-003: Late Audit Submission Response: We were unaware that we had to complete a federal audit for FY 2023. We will confirm with the auditor in future years to make sure we are not late.

View Audit 310727

Finding 403707 (2023-002)

Material Weakness 2023

Wayne Metropolitan Community Action Agency and Affiliates

MI

Questioned Costs Procurement, Suspension & Debarment Material Weakness

The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions...

The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions and such documentation must match the requisition in vendor name, address, amount, invoice number and appropriate program code. Staff have been trained on the use of the purchase requisition system and briefed on the necessary documentation standards.

View Audit 310726 Questioned Costs: $1

Finding 403617 (2023-001)

Significant Deficiency 2023

Hospital Development Company D/b/a Roane General Hospital

WV

Special Tests & Provisions Questioned Costs Reporting

Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt servic...

Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt service coverage ratio of at least 1.25, days cash on hand in excess of 65 days, and obtaining an audited fiscal year-end financial statement audited by independent certified public accountants withing one hundred ten days subsequent to year end. Additionally, section 4(d) of the Community Facilities Loan Resolution Agreement stipulates that the Hospital will establish and maintain a bookkeeping or separate bank account for the debt reserve funds. As of September 30, 2023 the Hospital had not maintained a separate account at the bank with sufficient funds, nor was a separate general ledger account established. Condition and Context: The Hospital did not maintain a days cash on hand in excess of 65 days, as of September 30, 2023. Additionally, the Hospital failed to maintain a separate account at the bank with sufficient funds, nor was a separate general ledger account established. The Hospital's audited financial statements as of September 30, 2023 were issued subsequent to one hundred ten days following September 30, 2023. Corrective Action Planned: Management has contacted the financial institutions and the United States Department of Agriculture, for waivers of debt covenants to prevent triggering an event of default. Additionally, management has reviewed and modified its internal controls to ensure monitoring of ongoing compliance. Name of Contact Person Responsible for Corrective Action: Amy Downey, Chief Financial Officer, 200 Hospital Drive, Spencer, WV 25276 Anticipated Completion Date: June 27, 2024

View Audit 310662

Finding 403590 (2023-002)

Material Weakness 2023

Guam Housing and Urban Renewal Authority

GU

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding #2023-002 Continuum of Care Program Views of Responsible Officials and Planned Corrective Action The Authority will review its accounting processes to accurately record and provide complete reports as required by the U.S. Housing and Urban Development (HUD), by the recommendations from HUD’s...

Finding #2023-002 Continuum of Care Program Views of Responsible Officials and Planned Corrective Action The Authority will review its accounting processes to accurately record and provide complete reports as required by the U.S. Housing and Urban Development (HUD), by the recommendations from HUD’s technical assistance, and by the updated Uniform Guidance requirements to report matching requirements. Responsible accounting and planning personnel will be trained on updated Uniform Guidance. Responsible Party: Frances Danieli, Controller and Katherine Taitano, Chief Planner Anticipated Date of Completion: Ongoing effort and as training is made available

View Audit 310613 Questioned Costs: $1

Finding 403578 (2023-001)

Significant Deficiency 2023

Family Health International

NC

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for...

Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for Economic Growth Federal Award Identification Number: 98.001 - 7200AA19CA00002; 72066418CA00001; 72044020CA00002; 72049218CA00008; 72066418CA00001; 7200AA18CA00011; 72066322CA00005. 98.U04 - 72026320C00005 Award Year: FY 2022 – 2023 Corrective Action Plan: FHI 360 will implement a corrective action plan comprised of the following actions: 1.) additional global communications and meetings with key management teams; 2.) targeted and detailed training on FFATA requirements and completion of the FSRS template via an e-module; and 3.) implement an additional review through a small, centralized team both to identify prospective transactions and perform a final review of data quality prior to data entry in FSRS. Person(s) Responsible: Director, Contract Management Services Chief Operating Officer Completion Date: July 31, 2024

View Audit 310612

Finding 403480 (2023-012)

Significant Deficiency 2023

Crow Wing County

MN

Matching / Level of Effort / Earmarking Questioned Costs Eligibility

EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with ...

EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement a review policy to ensure they are following compliance requirements for administrative expenditure reporting. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024

View Audit 310545

Corrective Action Plans

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