Corrective Action Plans

Finding 1228639 (2022-006)

Material Weakness 2022

NC

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.334

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Caroli...

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Carolina League of Municipalities to provide additional training to the Town ‘s staff. Proposed Completion Date: December 31, 2026.

View Audit 410277

Finding 1224365 (2022-003)

Material Weakness 2022

Russellville Hospital, Inc.

AL

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.512

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: 09/30/2026

View Audit 407672

Finding 1224364 (2022-004)

Material Weakness 2022

Russellville Hospital, Inc.

AL

Questioned Costs Material Weakness Reporting

The loan was acquired from previous owners of the hospital and was obtained by current owners at the time of purchase. This year was the first year the program was required to be audited. We are actively working to ensure this condition is met by ensuring the reserve fund is met, the debt service co...

The loan was acquired from previous owners of the hospital and was obtained by current owners at the time of purchase. This year was the first year the program was required to be audited. We are actively working to ensure this condition is met by ensuring the reserve fund is met, the debt service coverage ratio of at least 1.0 is obtained, and audited financials available to USDA annually. Anticipated completion date: 09/30/2026

View Audit 407672

Finding 1224134 (2022-004)

Material Weakness 2022

STRESS & TRAUMA TREATMENT CENTER INC

IL

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

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly dis...

Condition: During our testwork, we noted three employees were missing time and effort certifications. Plan: The Organization is implementing written policies and procedures over time and effort reporting to ensure proper documentation is always maintained or complete in all instances to properly distribute salary and benefit costs for employees who work in whole or in part on grant program activity in accordance with the Uniform Guidance. This includes having the documentation reviewed and formally approved by a supervisor. Anticipated Date of Completion: December 31, 2026 Name of Contact Person: Matt Buckman, Executive Director

View Audit 407517

Finding 1223980 (2022-002)

Material Weakness 2022

NEW YORK MORTGAGE COALITION, INC.

NY

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

Management will review its policies and procedures to ensure that all quarterly reports and the supporting documentation used to prepare the reports are retained for audit purposes. All the reports will be reviewed and approved by someone other than the preparer prior to submission.

View Audit 407388

Finding 1223299 (2022-005)

Material Weakness 2022

Mesalands Community College

NM

Matching / Level of Effort / Earmarking Questioned Costs Subrecipient Monitoring

The College plans to include the information for the Foundation with its audit which will enable management to reconcile information to ensure correct balances are available for reporting. The planned completion date for the upgrades to the processes and systems is December 31, 2024. The responsible...

The College plans to include the information for the Foundation with its audit which will enable management to reconcile information to ensure correct balances are available for reporting. The planned completion date for the upgrades to the processes and systems is December 31, 2024. The responsible party is the Finance Director.

View Audit 406800

Finding 1222697 (2022-005)

Material Weakness 2022

Veterans Transition Center of California

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.307

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be ...

View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years, including the establishment of policies and procedures to ensure that program income is tracked by contract and expended in accordance with applicable federal requirements.

View Audit 406305

Finding 1216732 (2022-002)

Material Weakness 2022

STEPS to Recovery Homes

AZ

Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions

Management of the Organization has an accounting firm engaged who will perform future required audits.

View Audit 403176

Finding 1216173 (2022-010)

Material Weakness 2022

Virgin Islands Port Authority

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Authority will retain emails between preparers and reviewers for forms that cannot be signed.

View Audit 402648

Finding 1216172 (2022-009)

Material Weakness 2022

Virgin Islands Port Authority

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the submission requirement is unclear, the Authority will consult with its federal partner to obtain a determination.

View Audit 402648

Finding 1216171 (2022-008)

Material Weakness 2022

Virgin Islands Port Authority

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filin...

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filings and maintains a working spreadsheet of items sent. In addition, Accounting has implemented a tickler system to remind staff to submit financial reports to Engineering or the grantor.

View Audit 402648

Finding 1216167 (2022-006)

Material Weakness 2022

Virgin Islands Port Authority

VI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.

View Audit 402648

Finding 1214375 (2022-011)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.305

2022-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...

2022-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 401032

Finding 1214365 (2022-001)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2022-001 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...

2022-001 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 401032

Finding 1214251 (2022-002)

Material Weakness 2022

Urban Partnerships Community Development Corporation

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management ...

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management will implement proper policies and procedures to ensure the Organization and Affiliates' activities are properly recognized. In addition, management will reconcile the activities of the Organization and Affiliates quarterly against the financial system and ensure activities are recognized properly at year-end.

View Audit 400976

Finding 1214201 (2022-008)

Material Weakness 2022

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a sy...

Department of Housing and Urban Development and Department of Veterans Affairs 2022-008 Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 400920

Finding 1214199 (2022-007)

Material Weakness 2022

Open Door Ministries of High Point, Inc.

NC

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.334 § 200.337

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally re...

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend that management retain all documents including evidence of participant eligibility under the program until the latter of the legally required retention period or completion of required audits and have the records available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented enhanced record retention and documentation controls to ensure that all participant eligibility documentation, supporting records, and program files are retained in accordance with federal retention requirements and made available upon request for audit or monitoring purposes. The Organization has created standardized eligibility documentation checklists and file review procedures to ensure completeness of required records. Additionally, records are now maintained in a centralized and secure format (physical and/or electronic), with clear retention timelines and assigned staff accountability for ongoing compliance and periodic file reviews. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 400920

Finding 1213658 (2022-002)

Material Weakness 2022

CANNON STREET YOUNG MENS CHRISTIAN ASSOCIATION

SC

Matching / Level of Effort / Earmarking Special Tests & Provisions

Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and conside...

Auditors’ recommendation: The Organization should modify its operations to the extent possible to improve operating results and stay in compliance with the loan agreement and debt workout agreement with the USDA. Auditee’s response: The Organization recognizes the challenges it is facing and considers its plan a sound approach to reaching compliance with the loan provisions in the debt workout agreement and loan agreement with the USDA.

View Audit 400599

Finding 1211144 (2022-005)

Material Weakness 2022

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400353

Finding 1211141 (2022-002)

Material Weakness 2022

Carestl Health

MO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations

View Audit 400353

Finding 1210493 (2022-005)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1210478 (2022-004)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Cash Management Questioned Costs Subrecipient Monitoring § 200.3 § 200.305

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US T...

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1208190 (2022-005)

Material Weakness 2022

Christian Theological Seminary, Inc.

IN

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.

View Audit 399050

Finding 1208189 (2022-004)

Material Weakness 2022

Christian Theological Seminary, Inc.

IN

Student Financial Aid Matching / Level of Effort / Earmarking

The Financial Aid Director, in conjunction with the Registrar, will review all student withdrawals to ensure that R2T 4 calculations are completed on time. At the midpoint of the semester and other review will be done to ensure that all calculations were completed and on time.

View Audit 399050

Finding 1206398 (2022-001)

Material Weakness 2022

City of Newark

NJ

Eligibility Matching / Level of Effort / Earmarking

It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.

View Audit 398402

Corrective Action Plans

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