Corrective Action Plans

Finding 573484 (2024-007)

Material Weakness 2024

City of Lodi

CA

Reporting Allowable Costs / Cost Principles Material Weakness

Reference Number: 2024-007 – Delays in Financial Reporting Name of Contact Person: Chia Lor, Accounting Manager Corrective Action: Management agrees with the finding. The City has filled all of its vacant positions in Accounting and anticipates a timely completion of the 2024/25 Audit. Proposed...

Reference Number: 2024-007 – Delays in Financial Reporting Name of Contact Person: Chia Lor, Accounting Manager Corrective Action: Management agrees with the finding. The City has filled all of its vacant positions in Accounting and anticipates a timely completion of the 2024/25 Audit. Proposed Completion Date: December 31, 2025

View Audit 364209

Finding 573474 (2024-004)

Material Weakness 2024

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs HUD Housing Programs Reporting

4. Finding 2024-004 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding This is related to the deposit error in 2024-002. North TX A/C repaid one deposit on Septemb...

4. Finding 2024-004 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding This is related to the deposit error in 2024-002. North TX A/C repaid one deposit on September 30, 2024 and will repay the remaining one-month deposit to the property. These funds will be correctly deposited into the replacement reserve account going forward. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Audit Findings, Questioned Costs and Recommendations 1. Finding 2023-001 In process. See finding 2024-003.

View Audit 364206 Questioned Costs: $1

Finding 573473 (2024-003)

Material Weakness 2024

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs HUD Housing Programs Reporting

3. Finding 2024-003 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding 2 HUD approved the $75,000 repaid as a response to a 2022 finding. HUD has not reached out t...

3. Finding 2024-003 a. Comments on the Finding and Each Recommendation Management agrees with the finding and is taking steps to address the issue that caused it. b. Action(s) Taken or Planned on the Finding 2 HUD approved the $75,000 repaid as a response to a 2022 finding. HUD has not reached out to management for repayment of the $23,000, however, management will seek evidence of HUD approval for the remaining $23,000 repaid.

View Audit 364206 Questioned Costs: $1

Finding 573467 (2024-003)

Material Weakness 2024

Bibb County Board of Education

AL

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions

We are award of the Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "David-Bacon Act") when using COVID-19 Education Stabilizaiton Funds to fund construction contracts in excess of $2,000. We will ensure the Davis-Bacon Act ...

We are award of the Title 29, U.S. Code of Federal Regulations, Part 5, Sub-Part A Davis Bacon and Related Acts Provisions and Procedures (the "David-Bacon Act") when using COVID-19 Education Stabilizaiton Funds to fund construction contracts in excess of $2,000. We will ensure the Davis-Bacon Act wage rate is included in all construction contracts over $2,000.

View Audit 364195 Questioned Costs: $1

Finding 573383 (2024-003)

Material Weakness 2024

County of Sutter

CA

Reporting Allowable Costs / Cost Principles Material Weakness

Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Due to extenuating circumstances resulting in delays from the ERP implementation, the County made efforts to inform the cognizant agencies and requested a filing...

Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Due to extenuating circumstances resulting in delays from the ERP implementation, the County made efforts to inform the cognizant agencies and requested a filing extension. Unfortunately, the extension request was denied. The County does not anticipate these delays will affect future reporting periods as they were one-time occurrences due to system conversion and post go-live difficulties. The County has been compliant with Single Audit submission deadline for at least the 9 prior years. Proposed Completion Date 08/08/2025

View Audit 364158

Finding 573382 (2024-004)

Significant Deficiency 2024

County of Sutter

CA

Significant Deficiency Matching / Level of Effort / Earmarking

Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Development Services sent certified letters to loan recipients and retained certified or returned mail. In some cases, the department sent up to 4 letters and ph...

Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Development Services sent certified letters to loan recipients and retained certified or returned mail. In some cases, the department sent up to 4 letters and physically verified the houses are still occupied. Code Enforcement staff also hand delivered letters to some of the non-responsive loan recipients. Moreover, the Department has secured the services of an outside consultant, Adams Ashby Group, to review and assist in efforts to comply with the loan requirements and provide their outside opinion on best practice in handling loans. Lastly, the Department is working with County Administrator's Office, Treasurer-Tax Collector's Office, and County Counsel on proper and legal way to handle sold properties, delinquent taxes, or simply not responding to the County's correspondence and requests. Proposed Completion Date Ongoing process.

View Audit 364158

Finding 573352 (2024-007)

Significant Deficiency 2024

Leech Lake Tribal College

AZ

Student Financial Aid Reporting Significant Deficiency § 200.328

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

View Audit 364132

Finding 573347 (2024-006)

Significant Deficiency 2024

Leech Lake Tribal College

AZ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

View Audit 364132

Finding 573315 (2024-003)

Material Weakness 2024

Ouachita Parish Police Jury

LA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.328

Management acknowledges the need for compliance with reporting requirements for COVID-19 State and Local Fiscal Recovery Funds. We will follow the auditors’ recommendation to review our policies and procedures to ensure that internal controls are properly designed, implemented and maintained to ensu...

Management acknowledges the need for compliance with reporting requirements for COVID-19 State and Local Fiscal Recovery Funds. We will follow the auditors’ recommendation to review our policies and procedures to ensure that internal controls are properly designed, implemented and maintained to ensure accurate and timely financial close and reporting.

View Audit 364114

Finding 573274 (2024-003)

Significant Deficiency 2024

Sunrise Residential, Inc.

IL

HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding Reference Number: 2024-03 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure cash disbursements of project funds are limited to project operating costs. Expens...

Finding Reference Number: 2024-03 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure cash disbursements of project funds are limited to project operating costs. Expense paid from project funds for an affiliated project will be reimbursed to the project. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Billie Williams, President of Active Real Estate Management Completion Date: Open

View Audit 364065

Finding 573272 (2024-002)

Significant Deficiency 2024

Sunrise Residential, Inc.

IL

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

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP con...

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP contract. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Billie Williams, President of Active Real Estate Management Completion Date: Open

View Audit 364065

Finding 573227 (2024-001)

Material Weakness 2024

Vermont Youth Conservation Corp, Inc.

VT

Questioned Costs Matching / Level of Effort / Earmarking Reporting

Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. ...

Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. Action Taken: Vermont Youth Conservation Corps, Inc. has implemented procedures to ensure grant matching requirements are satisfied at the time of final report submission. If Corporation for National and Community Service (CNCS) has any questions regarding this plan, please call Hapy Mayer at (802) 434-3969 ext. 134.

View Audit 364046 Questioned Costs: $1

Finding 573214 (2024-002)

Material Weakness 2024

East Phillips CO Hospital Dist Dba Melissa Memorial Hospital

CO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses...

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses to verify that they are appropriate and in the correct accounting period. A procedure will be implemented to ensure that at year-end, all grant revenues and expenses are double-checked to verify they are posted in the correct period. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO

View Audit 364026

Finding 573196 (2024-002)

Significant Deficiency 2024

City of Topeka, Kansas

KS

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The re...

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The report will then be completed and submitted as the official report. The approval will be documented via email or other written confirmation. All approval records will be saved in the designated quarterly report file at or before the time of submission. If another staff member prepares or adjusts the report (e.g., due to leave), they will also document and save evidence of approval in the designated quarterly report file. Moving forward, the City will consistently retain documented approvals as part of the reporting process. Planned Completion Date: These modifications are being implemented immediately. Contact Person Responsible for Correction Action: Joshua McAnarney, Division Director of Finance & Budget or Designee

View Audit 364022

Finding 573161 (2024-001)

Significant Deficiency 2024

Clear Path for Veterans New England, Inc.

MA

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

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility ...

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility to ensure that participants are recertified within the allowable time frame. Anticipated Completion Date September 2025

View Audit 363979

Finding 573160 (2024-002)

Significant Deficiency 2024

New Jersey City University

NJ

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedu...

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedures and reduce the risk of future manual errors.

View Audit 363978

Finding 573159 (2024-001)

Material Weakness 2024

New Jersey City University

NJ

Student Financial Aid Subrecipient Monitoring Cash Management

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.

View Audit 363978

Finding 573158 (2024-003)

Significant Deficiency 2024

Hawaiian Shores Community Association

HI

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

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit fi...

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Association will make the required transfers in fiscal year 2025 to ensure compliance with loan requirements. Name of the contact person responsible for corrective action: Jeff Sargent Planned completion date for corrective action plan: May 1, 2025

View Audit 363975

Finding 573121 (2024-001)

Material Weakness 2024

The Addiction Center of Broome County, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal proces...

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal processes will be adjusted as needed. We will continue to monitor this area and document efforts to ensure ongoing alignment with applicable regulations. Contact Person Responsible for Corrective Action Plan: Lottie Albrecht, Director of Administration Phone Number: 607-940-0102 Email: lalbrecht@acbcservices.org Anticipated Completion Date of Corrective Action Plan: December 2025 (as part of preparation for fiscal year ending December 31, 2025)

View Audit 363928 Questioned Costs: $1

Finding 573036 (2024-001)

Material Weakness 2024

Banner Health

AZ

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

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025

View Audit 363912

Finding 573035 (2024-002)

Significant Deficiency 2024

Warren County, Missouri

MO

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.

View Audit 363908

Finding 573029 (2024-009)

Material Weakness 2024

City of Nogales Arizona

AZ

Special Tests & Provisions Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.326

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: ...

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: There was no support provided for the three out of three contractor vendors with construction work noted on their purchase orders to support compliance with Davis Bacon. Corrective Action Plan: Regarding the wage tests for the Park’s grant, no information was provided to the City from the contractor of employee wages paid by the contractor. An email request and answer from the contractor was forwarded to the auditors, that the contractor was not responsible to report the wages. This in the future will be part of the Grants Coordinator position for Internal Control purposes, to ensure that any future construction contracts include the wage reporting requirements. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Finding 572993 (2024-002)

Significant Deficiency 2024

La Clinica Tepeyac

CO

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

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.

View Audit 363862

Finding 572979 (2024-001)

Significant Deficiency 2024

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.

View Audit 363843 Questioned Costs: $1

Finding 572976 (2024-002)

Significant Deficiency 2024

Open Doors for Multicultural Families

WA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct t...

We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct the issue as of June 1, 2025. The Accounting Manager will send the monthly indirect cost allocation report to the Executive Director to review and approve prior to beginning any month-end billing process so if corrections are needed, they can be made prior to reimbursement requests being sent to the grant agency. We have also implemented a new month-end process as of June 1, 2025, for the Accounting Manager to provide a detailed GL report to each Program Manager to review and approve program expenses for the given month prior to any billing requests being submitted to the grant agency.

View Audit 363824

Corrective Action Plans

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