Corrective Action Plans

Finding 1206310 (2022-006)

Material Weakness 2022

MA

Cash Management HUD Housing Programs Material Weakness § 200.302 § 200.303 § 200.305

Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures ...

Item 2022.006 - Cash Manaaement Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval process, submission to the funding agency, and the recording of the drawdown in the accounting system immediately after submission • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices

View Audit 398372

Finding 1206309 (2022-007)

Material Weakness 2022

Island Health, Inc.

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

View Audit 398372

Finding 1206172 (2022-007)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Material Weakness § 200.512

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1206169 (2022-004)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Procurement, Suspension & Debarment HUD Housing Programs

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1206162 (2022-005)

Material Weakness 2022

Native Village of Barrow

AK

Reporting Procurement, Suspension & Debarment Material Weakness

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...

Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1182846 (2022-001)

Material Weakness 2022

Prevent Child Abuse Utah

UT

Material Weakness Internal Control / Segregation of Duties

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Ch...

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Child Abuse Utah evaluate the ongoing benefits and expenses of including this element into its system of internal control.

View Audit 394245

Finding 1179321 (2022-011)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.309 § 200.77

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreem...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete

View Audit 391683

Finding 1179320 (2022-010)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximiz...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations that are calculated in a consistent manner that ensure costs are applied uniformly to respective benefited activities, and that are reflective on employees’ time and effort records Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCAs overhead structure differs from department to department, which makes it difficult to develop a common framework. And quite often the Federal or State agency is prescriptive when it publishes its grant guidelines. Though these grants are developed and submitted more centrally than in the past; nonetheless we will endeavor to develop a common listing of approved cost allocations. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: December 2026

View Audit 391683

Finding 1179144 (2022-005)

Material Weakness 2022

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Material Weakness School Nutrition Programs

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 391539

Finding 1175930 (2022-002)

Material Weakness 2022

Head Start of Lane County

OR

Allowable Costs / Cost Principles Material Weakness

Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconci...

Head Start of Lane County has created a paln with assitance of Wipfli to complete outstanding audits. See corrective action item 2022-004 for more details. The agency has implemented a yearly closeout starting in the year 2024-2025 going forward. This will allow for timely audit preparation, reconciliations and adjustments to occur

View Audit 389901

Finding 1174933 (2022-018)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174931 (2022-016)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency § 200.303

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174927 (2022-014)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Equipment & Real Property Management Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174926 (2022-013)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174138 (2022-002)

Material Weakness 2022

THE BELLEVUE HOSPITAL AND SUBSIDIARIES

OH

Reporting Matching / Level of Effort / Earmarking Material Weakness § 200.403

Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...

Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025

View Audit 387815

Finding 1172700 (2022-007)

Material Weakness 2022

Northwest Indian College

WA

Material Weakness Internal Control / Segregation of Duties § 200.303

Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF fu...

Recommendation: We recommend the college retain evidence of the review of student accounts prior to disbursement of HEERF funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: No longer disbursing student HEERF funds. Discussions have taken place between Financial Aid department and Accounting staff requesting that supporting documentation is retained to show evidence that the College reviewed student accounts and eligibility prior to student disbursements. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Finding 1172528 (2022-004)

Material Weakness 2022

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.

View Audit 385755

Finding 1172527 (2022-003)

Material Weakness 2022

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring HUD Housing Programs Material Weakness

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.

View Audit 385755

Finding 1172526 (2022-002)

Material Weakness 2022

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Eligibility HUD Housing Programs Material Weakness

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...

HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.

View Audit 385755

Finding 1171938 (2022-001)

Material Weakness 2022

MOBILE COMMUNITY ACTION, INC.

AL

Material Weakness Internal Control / Segregation of Duties

• All outstanding accounts have been reviewed and reconciled, and variances have been· resolved and documented.

View Audit 384981

Finding 1171938 (2022-001)

Material Weakness 2022

MOBILE COMMUNITY ACTION, INC.

AL

Material Weakness Internal Control / Segregation of Duties

• A formal monthly reconciliation schedule has been implemented for all key accounts.

View Audit 384981

Finding 1171938 (2022-001)

Material Weakness 2022

MOBILE COMMUNITY ACTION, INC.

AL

Material Weakness Internal Control / Segregation of Duties

· Clear responsibility and supervisory review requirements have been assigned.

View Audit 384981

Finding 1171938 (2022-001)

Material Weakness 2022

MOBILE COMMUNITY ACTION, INC.

AL

Material Weakness Internal Control / Segregation of Duties

• Monitoring procedures have been strengthened to ensure timeliness and documentation compliance

View Audit 384981

Finding 1171938 (2022-001)

Material Weakness 2022

MOBILE COMMUNITY ACTION, INC.

AL

Material Weakness Internal Control / Segregation of Duties

• Future audit engagement timelines will be coordinated to align with the organization's normal financial reporting cycle to minimize risk.

View Audit 384981

Finding 1170482 (2022-002)

Material Weakness 2022

Alameda County Deputy Sheriff's Activities League Inc.

CA

Material Weakness Reporting

Management's Response: DSAL will attempt to meet the annual filing requirements. Estimated Completion Date: May 2025 Responsible Party: Sara Sherman, Contract Finance Manager

View Audit 383671

Corrective Action Plans

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