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Corrective Action Plans

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Finding 571651 (2024-002)
Material Weakness 2024
Hennepin County Minnesota
MN
Eligibility Allowable Costs / Cost Principles Material Weakness
Program(s): Supplemental Nutrition Assistance Program (SNAP). Assistance Listing Number 10.561 Type of Finding: Material Weakness in Internal Control over Compliance Condition: During our testing, we noted the following three instances of noncompliance in the sample of forty case files tested:...
Program(s): Supplemental Nutrition Assistance Program (SNAP). Assistance Listing Number 10.561 Type of Finding: Material Weakness in Internal Control over Compliance Condition: During our testing, we noted the following three instances of noncompliance in the sample of forty case files tested: • One MAXIS case files did not have a renewal application on file. • One MAXIS case file did not have a signed application on file. • One MAXIS case file did not have documentation matching the income on file. In addition, the County does not have a formalized supervisory case file review process in place to ensure accuracy and completeness of inputs into the eligibility determination system, MAXIS. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered, and the information required by the contract will be retained in the County’s records Hennepin County Employee Responsible for the CAP: Jennifer Frey Planned Completion Date for CAP: December 31, 2025
View Audit 362609
Brockwood Community Association 054-11142
NC
Procurement, Suspension & Debarment HUD Housing Programs Reporting § 200.512
Brockwood Community Association 801 W. Washington Street Greenville, South Carolina 29601 CORRECTIVE ACTION PLAN April 14, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida...
Brockwood Community Association 801 W. Washington Street Greenville, South Carolina 29601 CORRECTIVE ACTION PLAN April 14, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Brockwood Community Association respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The finding from the year ended December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - Federal Award Program Audit Finding 2024-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend the board of directors and management ensure that the audit and data collection forms are completed timely and the data collection form and required reporting package are submitted electronically to the FAC each fiscal year going forward by the required due date. Action Taken: We agree with Finding 2024-003 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will provide additional oversight to ensure the data collection forms are submitted electronically to the FAC each fiscal year going forward within required due dates. If HUD has questions regarding this corrective action plan, please call (704) 771-1696. Sincerely yours, Claudia A Keene, CPA Controller Multifamily Select, Inc.
View Audit 362600
Finding 571591 (2024-008)
Significant Deficiency 2024
Housing Authority of the City of Seattle
WA
HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority implement a higher-level review of the HUD-50058 listing that gets uploaded to the PIC system. We also recommend providing additional training to case management employees to ensure ...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority implement a higher-level review of the HUD-50058 listing that gets uploaded to the PIC system. We also recommend providing additional training to case management employees to ensure that they are aware of the necessity for the property code to be reported accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Compliance team will provide continued specific training in data entry elements critical to PIC upload processes. Compliance will audit properties that do not submit 50058 reports to PIC to ensure households are not incorrectly categorized. To prevent the error from coming up again, a report has been created to identify households with a program code that would preclude submission to PIC/IMS.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous. Preventive actions will be ongoing as part of the regular compliance and quality management process. As aforementioned, a report has been created to identify households with a program code that would preclude submission to PIC/IMS. The Data Analyst will review the report each month and verify with the Compliance Manager that the households on the report are appropriately categorized.
View Audit 362508
Finding 571589 (2024-006)
Significant Deficiency 2024
Housing Authority of the City of Seattle
WA
HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority review the controls in place to ensure that all required recertification documents are completed, signed, and in the tenant's file. Explanation of disagreement with audit finding: T...
Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend that the Authority review the controls in place to ensure that all required recertification documents are completed, signed, and in the tenant's file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has adopted the updated HUD-9886-A in addition to its own Release of Information. The updated release form does not expire and provides more indefinite Release of Information coverage. An additional data field has been created to track households that opt out of their release.. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Preventive actions to identify households that opt out of the adopted indefinite Release of Information will be ongoing as part of the regular compliance and quality management process.
View Audit 362508
Finding 571541 (2024-005)
Material Weakness 2024
Tca Health, Inc.
IL
Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303 § 200.305
Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be do...
Recommendation: We recommend management consider developing a contingency plan for when there is turnover in key personnel involved with the drawdown process of federal grants. As part of this plan, if changes need to occur to the primary internal control over drawdowns, those changes should be documented with supporting documentation retained for the revised internal control. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA will have a Grant/Staff Account or designee prepare documentation for the drawdowns. The CEO or designee will approve drawdown documents. CFO/Controller or designee will process the drawdown and take a screenshot when completed. All approvals will be shown on the excel sheet with the drawdown information. Name(s) of the contact person(s) responsible for corrective action: Jeremy Runde, Controller Planned completion date for corrective action plan: June 2025
View Audit 362500
Finding 571539 (2024-003)
Material Weakness 2024
Tca Health, Inc.
IL
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430
Recommendation: Management should reenforce the requirement to retain time and effort documentation for all employees that are allocated to multiple grants and implement a review process whereby the allocation percentages used are compared to the employee attestations provided. Explanation of disag...
Recommendation: Management should reenforce the requirement to retain time and effort documentation for all employees that are allocated to multiple grants and implement a review process whereby the allocation percentages used are compared to the employee attestations provided. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA has changed the time and effort sheet to be less confusing for staff. Also, we can set up allocations in our payroll system which the employee and supervisor have to sign off on their time card for each payroll. Name(s) of the contact person(s) responsible for corrective action: Jeremy Runde, Controller Planned completion date for corrective action plan: June 2025
View Audit 362500 Questioned Costs: $1
Finding 571535 (2024-001)
Material Weakness 2024
Housing Authority of the City of Greenwood
MS
Material Weakness Matching / Level of Effort / Earmarking
Non-compliance with the Davis-Bacon Act Corrective Action The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Dr. Earl Hall, has assumed the responsibility of execut...
Non-compliance with the Davis-Bacon Act Corrective Action The Authority will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Authority’s Executive Director, Dr. Earl Hall, has assumed the responsibility of executing this corrective action as of July 1, 2025.
View Audit 362478
Housing Authority of the City of Greenwood
MS
HUD Housing Programs Matching / Level of Effort / Earmarking
Insufficient Collateralization of Deposits Corrective Action The Authority will monitor security over bank deposits regularly. The Authority’s Executive Director, Dr. Earl Hall, has assumed the responsibility of executing this corrective action as of July 1, 2025.
Insufficient Collateralization of Deposits Corrective Action The Authority will monitor security over bank deposits regularly. The Authority’s Executive Director, Dr. Earl Hall, has assumed the responsibility of executing this corrective action as of July 1, 2025.
View Audit 362478
Finding 571506 (2024-002)
Material Weakness 2024
McNary Elementary School District No. 23
AZ
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.333
The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.
The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.
View Audit 362459
Finding 571503 (2024-006)
Material Weakness 2024
City of Loveland
CO
Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.502 § 200.508 § 200.510
Condition: The schedule of expenditures of federal awards (the "SEFA") was not accurate. Planned Corrective Action: To improve accuracy and completeness of the SEFA, the City will enhance its master grant tracking spreadsheet to ensure all grant expenses are calculated correctly and consistently. I...
Condition: The schedule of expenditures of federal awards (the "SEFA") was not accurate. Planned Corrective Action: To improve accuracy and completeness of the SEFA, the City will enhance its master grant tracking spreadsheet to ensure all grant expenses are calculated correctly and consistently. In addition, quarterly reviews will be conducted in partnership with departments to confirm that all federal awards are current and accurately captured. These improvements, along with the updated required quarterly report and request for reimbursement procedures, will allow the City to compile a complete and accurate SEFA. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 7/31/2025
View Audit 362454
Finding 571502 (2024-005)
Material Weakness 2024
City of Loveland
CO
Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking
Condition: The City did not have controls in place surrounding the review of contracts and bid documents and omitted the prevailing wage rates provisions from the construction contract it entered into that was financed by the federal award. Planned Corrective Action: While the City did have sufficie...
Condition: The City did not have controls in place surrounding the review of contracts and bid documents and omitted the prevailing wage rates provisions from the construction contract it entered into that was financed by the federal award. Planned Corrective Action: While the City did have sufficient internal policy in place to ensure compliance with 2 CFR 200 procurement requirements, the City failed to follow such procedures, despite compliance in practice. To address this, the City will revise both its Grants Management and Procurement Administrative Regulations to ensure that all required federal provisions are explicitly included in all applicable solicitations and contracts. Updated procedures will reinforce alignment between policy and practice. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 7/31/2025
View Audit 362454
Finding 571500 (2024-003)
Material Weakness 2024
City of Loveland
CO
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303
Condition: The City did not have controls in place surrounding the review of requests for reimbursement to ensure the underlying invoices were allowable and that the local matching contribution was calculated correctly. Planned Corrective Action: The City will revise its Grants Management Administra...
Condition: The City did not have controls in place surrounding the review of requests for reimbursement to ensure the underlying invoices were allowable and that the local matching contribution was calculated correctly. Planned Corrective Action: The City will revise its Grants Management Administrative Regulation to require that all requests for reimbursement be submitted on a quarterly basis. Each RFR will be required to go through a documented review by a finance staff member prior to submission to ensure accuracy and appropriate application of required match. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 07/31/2025
View Audit 362454
Finding 571499 (2024-002)
Material Weakness 2024
City of Loveland
CO
Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.303
Condition: The City did not have controls in place surrounding the filing of semi-annual performance and financial reports nor did it submit the required reports. Planned Corrective Action: Ensure that all annual reports for all federal programs have a required secondary review by a finance staff me...
Condition: The City did not have controls in place surrounding the filing of semi-annual performance and financial reports nor did it submit the required reports. Planned Corrective Action: Ensure that all annual reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy, and timeliness of submission. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 6/30/2025
View Audit 362454
Finding 571498 (2024-001)
Material Weakness 2024
City of Loveland
CO
Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303
Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy...
Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy, and timeliness of submission. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 6/30/2025
View Audit 362454
Finding 571488 (2024-001)
Material Weakness 2024
Deschutes Land Trust
OR
Reporting Internal Control / Segregation of Duties Material Weakness § 200.303
WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there i...
WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: Ensure the Stewardship Director reviews and signs the SF-425. Action Plan: Amend existing policies associated with federal grants, to require the Program Director responsible for overseeing projects using federal funds to sign any required and submitted financial reports. Name(s) of the contact people responsible for correction action: Michael Rubovits Plan completion date for corrective action plan: 8/31/2025
View Audit 362417
Finding 571482 (2024-003)
Significant Deficiency 2024
Eastern Plains Community Action Agency, Inc.
NM
Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking
We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy ...
We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy in place to correct this finding that was approved by the board on August 9, 2024.
View Audit 362404
Healthfirst Bluegrass INC
KY
Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking
Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit t...
Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit the application of sliding fee discounts on the patient accounts consistent with policy.
View Audit 362384
Finding 571464 (2024-006)
Significant Deficiency 2024
City and County of Denver
CO
Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recom...
Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the City establish and implement a formal process to consistently retain documentation of FFATA report submission dates, as well as evidence of the review and approval of each report submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Denver’s Department of Economic Development and Opportunity (DEDO) will establish a formal approval process to establish and document submission dates of all FFATA filings going forward. While the Federal Government does not provide any timestamps of initial submission for FFATA filings, nor require approval for FFATA submissions, DEDO will begin providing written and dated approvals of when FFATA reporting is taking place. We will put together a formal process that will provide dates to show review/approval of FFATA filings to meet our external auditor’s request, despite the Federal Government not requiring it. DEDO is able to provide a documented historical consistency of maintaining effective internal controls over this Federal award, and will begin including FFATA filings in the documentation that is already maintained showing timely submission of reporting to the Federal Government. Name(s) of the contact person(s) responsible for corrective action: Fanta Harkiso & Derek Cary Planned completion date for corrective action plan: August 31, 2025
View Audit 362374
Finding 571462 (2024-005)
Significant Deficiency 2024
City and County of Denver
CO
Matching / Level of Effort / Earmarking § 200.303
Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user acce...
Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user access rights are offboarded timely when employees separate employment or move departments that do not require them to keep CBMS access. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Add Second Level verification: DHS Help Desk supervisor will be copied on Departure notices from Human Resources. The DHS Help Desk Supervisor will match IAM offboard notices from State OIT to Internal Human Resources Departure notices on a weekly basis and follow-up on any unmatched items. Name(s) of the contact person(s) responsible for corrective action: Carl Ellis, TS IT Supervisor Planned completion date for corrective action plan: April 1, 2025
View Audit 362374
Finding 571438 (2024-004)
Material Weakness 2024
Town of Paoli
IN
Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Material Weakness § 200.302 § 200.303 § 200.328 § 200.329
FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Descrip...
FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately
View Audit 362372
Finding 571391 (2024-001)
Material Weakness 2024
St. Vincent General Hospital District
CO
Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.
View Audit 362330
Finding 571386 (2024-001)
Material Weakness 2024
City of Laporte
IN
Internal Control / Segregation of Duties Special Tests & Provisions HUD Housing Programs § 200.303
FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary ...
FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary Report (PR26) The City of La Porte Community Development Block Grant will submit the following report to the Clerk/Treasurer and Director of Community Development and Planning for review and approval prior to submitting to HUD: PR26 Annual Financial Summary. Special Tests and Provisions - Environmental Reviews The City of La Porte Community Development Block Grant will develop a checklist listing forms and correspondence required when completing an environmental review. The Director of Community Development and Planning will review the environmental review file and sign the checklist thereby indicating the environmental review is complete and properly maintained. Special Tests and Provisions – Rehabilitation The City of La Porte Community Development Block Grant will develop a evaluation form for the Director of Community Development and Planning to review to compare the initial site visit, work scope, and certificate of completion is properly maintained. The Community Development Block Grant program manager will initiate the form for review by the Director of Community Development and Planning at the end of the rehab activity per address. Anticipated Completion Date: July 1, 2025
View Audit 362316
Finding 571254 (2024-003)
Material Weakness 2024
Rccc Villa
IA
HUD Housing Programs Matching / Level of Effort / Earmarking
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
View Audit 362177
Rccc Villa
IA
HUD Housing Programs Matching / Level of Effort / Earmarking
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.
View Audit 362177
Finding 571166 (2024-002)
Material Weakness 2024
Midmichigan Health Services
MI
Subrecipient Monitoring Material Weakness Reporting § 200.303
Finding Number: 2024-002 Condition: Internal control procedures were not documented with enough evidence to support reports were being reviewed throughout the year. Additionally, due to entries identified and recorded during the 2024 financial statement audit of the Company, the data submitted with...
Finding Number: 2024-002 Condition: Internal control procedures were not documented with enough evidence to support reports were being reviewed throughout the year. Additionally, due to entries identified and recorded during the 2024 financial statement audit of the Company, the data submitted within the annual performance report was not accurate. Planned Corrective Action: Since the FY 2024 financial and single audit adjustments were not discovered and completed prior to the UDS submission deadline of 3/31/2025 and there is no mechanism to change UDS values after the deadline we will move the audit engagement earlier in the 2026 year to allow time to correct any UDS issues prior to 3/31/2026 deadline. Contact person responsible for corrective action: William E Collin, CFO Anticipated Completion Date: 3/31/2026
View Audit 362079
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