Corrective Action Plans

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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.
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-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fisca...
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-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. CFDA numbers for new federal awards will be identified, along with the applicable compliance requirements in accordance with the OMB Compliance Supplement (Matrix of Federal Compliance Requirements). Policies and procedures will be established for each applicable compliance requirement and will be communicated to employees responsible for monitoring and ensuring compliance.
Finding 2022-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...
Finding 2022-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program are in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.
2022-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will...
2022-013 Support for Payroll Material Weakness Recommendation: Auditor’s recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2022-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as de...
2022-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as defined under policy. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
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.
2022-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-ce...
2022-007 Tenant Eligibility Material Weakness Recommendation: In general, we continue to recommend a review of the re-certification process to determine areas of weakness. Specifically, we recommend the use of a standard checklist in the re-certification process. We further recommend that each re-certification clerk’s work be routinely audited. We also recommend more standardization in resident files organization of information, and procedures established to make sure all files are maintained adequately in order to be compliant. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...
2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2022-005 Timely Bank Reconciliations Material Weakness Recommendation: Implement currently adopted policies over bank reconciliations. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report
2022-005 Timely Bank Reconciliations Material Weakness Recommendation: Implement currently adopted policies over bank reconciliations. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report
2022-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction...
2022-004 Cash Management Material Weakness Recommendation: Auditors recommend filing documentation for grant draws along with payment vouchers throughout the year. Action Taken: Documentation for grant draws and expenditures to support the request for funding is vouchered along with wire transaction documentation that requires the signature of 3 Tribal Council for processing.
2022-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check ...
2022-002 Support for Expenditures Material Weakness Recommendation: Auditors recommend the governing board require proper documentation on all types of expenditures and that only members of the board have the authority to sign checks. Action Taken: The Tribal Chairperson has been a designated check signer as well as the St. Croix Tribal Council reviews revenue and expenditures on a monthly basis.
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
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
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.
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
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.
REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoin...
REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants t...
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
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
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
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.
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.
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.
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.
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