Corrective Action Plans

Finding 34729 (2022-002)

Material Weakness 2022

FL

HUD Housing Programs Material Weakness Reporting

2022-002 Reporting ? Inaccurate and Late FDS Submission and Late OMB Data Collection Form Submission Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Repeat finding of 2021-002 from March 31, 2021 Condition: The Authority?s origi...

2022-002 Reporting ? Inaccurate and Late FDS Submission and Late OMB Data Collection Form Submission Public and Indian Housing Program ? CFDA Number 14.850 Material Weakness in Internal Control Material Noncompliance Repeat finding of 2021-002 from March 31, 2021 Condition: The Authority?s original unaudited FDS filing was materially misstated. In addition, the Authority did not report the CARES Act activity in a separate column of the FDS as required. Also, the unaudited FDS filings were not submitted within the timeframes specified by HUD. The Authority submitted the unaudited FDS filing on May 26, 2023 (of which the normal due date was May 31, 2022). The Authority was also required to submit the audited FDS filing and the OMB Data Collection form to the Federal Audit Clearinghouse (?FAC?) by December 31, 2022 at completion of the single audit, but it was not filed timely, as the audit was completed on August 16, 2023. Recommendation: The Authority should make every effort to file its REAC submissions accurately and timely and submit the OMB Data Collection form timely. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were not able to accurately close the books before the HUD specified unaudited and audited FDS filing deadline and unable to timely file the OMB Data Collection Form. We are very focused on ensuring there is adequate staffing and sufficient processes in place in order to be able to close the books prior to submitting a materially accurate unaudited FDS submission for the following fiscal year as well as timely file the audited FDS and OMB Data Collection Form.

View Audit 30288

Finding 34728 (2022-001)

None 2022

Genesee Valley Presbyterian Nursing Center D/b/a Kirkhaven

NY

HUD Housing Programs Material Weakness Reporting § 200.516

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to becom...

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to become up to date in debt principal payments and escrow payments. Management Response Kirkhaven was and continues to be in communication with both HUD and mortgage servicer (Berkadia) with regards to the lack of payment of the October to December mortgage and escrow required payments amounting to $192,947 due to the cash flow challenges. They are aware of the executed CHOW Letter of Intent. Subsequent to year-end, Kirkhaven has made the required interest only payments for October to December and continues to make the monthly interest payments. Kirkhaven also has applied for relief of the required escrow payments, but was subsequently denied. Management will continue to monitor cash flow and if feasible make mortgage principal and escrow payments as able, however, the VAPAP grant proceeds did not include funds for debt payments. Managements position is that since the executed CHOW, intention is to use proceeds to pay of the mortgage balance, that paying the principal earlier versus later is less critical.

View Audit 36313

Finding 34711 (2022-002)

Material Weakness 2022

Fresno Pacific University and Subsidiaries

CA

Student Financial Aid Subrecipient Monitoring Material Weakness

Untimely Returns to Title IV (R2T4) Planned Corrective Action: We have trained and implemented processes to correctly determine period lengths and the earned and unearned percentages. We have increased the number of reports used to identify potential withdrawals. To correctly and timely process ...

Untimely Returns to Title IV (R2T4) Planned Corrective Action: We have trained and implemented processes to correctly determine period lengths and the earned and unearned percentages. We have increased the number of reports used to identify potential withdrawals. To correctly and timely process R2T4s, we outsourced the determination and calculation processes to a third-party vendor in November 2022 (this took longer than we anticipated). In March 2023, we were granted additional staffing resources and are in the process of hiring for those positions. To reduce the number of R2T4 calculations required, we also plan to switch from being an institution required to take attendance to a non-attendance taking institution for the 2023-2024 aid year. Person Responsible for Corrective Action Plan: Bryan Taylor, Associate Director of Student Financial Services Anticipated Date of Completion: May 2023

View Audit 37763

Finding 34692 (2022-001)

Material Weakness 2022

Stedman Volunteer Fire Department, Inc.

NC

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

The Board will discuss these recommendations and consider implementing procedures to further segregate duties within our internal control system.

View Audit 36137

Finding 34683 (2022-002)

Material Weakness 2022

Greater Lynn Senior Services, Inc.

MA

Material Weakness

The Organization will establish a monthly procedure to perform all allocations from administrative departments to programs and ensure proper sign-off of allocations.

View Audit 32401

Finding 34628 (2022-018)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-018 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 ...

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT 2022-018 Low-Income Home Energy Assistance, COVID-19 ? Low-Income Home Energy Assistance ? Assistance Listing No. 93.568 Action taken in response to the finding: Going forward, the FFATA will be submitted for LIHEAP by the DCS Fiscal Unit as required by FFATA instructions. Name of the contact person responsible for corrective action: Kristen Crowley Planned completion date for corrective action plan: Report will be filed in FSRS by the end of the month following the month in which the prime recipients are awarded. Next anticipated due date will be November or December 2023.

View Audit 31118

Finding 34609 (2022-011)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-011 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Reporting has been built to notify responsible parties of the award periods of performance and highlight any issues for corrective action in accordance to previously filed FFATA reporting. In addition, FFATA reporting has been created in EOLWD?s DataMart application. Actions taken are as follows: ? Performed FFATA training ? Created accounts for employee access to FFATA ? Filed existing outstanding and new grant FFATA reports ? Used new reporting to notify responsible parties that a new grant/modification has arrived and requires a FFATA Subaward report filed ? Training for existing staff complete and new staff will be trained accordingly as part of their onboarding. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: June 30, 2023

View Audit 31118

Finding 34608 (2022-010)

Material Weakness 2022

Commonwealth of Massachusetts

MA

Internal Control / Segregation of Duties Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17....

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2022-010 WIOA Cluster ? Assistance Listing No. 17.258, 17.259, 17.278 Action taken in response to the finding: Staffing: Two new Budget Analysts will begin working for EOLWD at the end of June in 2023. These analysts will provide additional capacity for filing 9130s for WIOA. Training: In March and April 2023, EOLWD provided training to new staff on the preparation, certification, and submission of 9130 reports. Staff beginning in June 2023 will be trained during the next 9130 reporting period. Automating Business Practices: EOLWD refined its automated 9130 reporting for the March 31, 2023, reporting period and is finalizing further refinements that will be implemented prior to the next quarterly reporting period. Standard Operating Procedures: EOLWD developed job aides for the preparation of 9130 reports with its new automated processes and is in the process of drafting new Standard Operating Procedures (SOP). These SOPs will be finalized and submitted to DOL by October 1, 2023, as outlined in the corrective action plan schedule provided to DOL. An updated version of this schedule is provided below. Name of the contact person responsible for corrective action: Malachy Rice, Director of Federal Grants, EOLWD Planned completion date for corrective action plan: October 1, 2023

View Audit 31118

Finding 34577 (2022-003)

Material Weakness 2022

Heart of America Medical Center

ND

Reporting Material Weakness

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal ...

Finding 2022-03 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution CFDA #93.498 Finding Summary: Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Responsible Individuals: Melissa Shepard, CFO and Erik Christenson, CEO Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for a complete and accurate consolidated schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the consolidated schedule of expenditures. We have designated a member of management to review the drafted consolidated schedule of expenditures. Anticipated Completion Date: Ongoing

View Audit 33781

Finding 34538 (2022-005)

Material Weakness 2022

Vista Homes Housing Corporation

NY

Allowable Costs / Cost Principles Special Tests & Provisions Material Weakness

Reporting views of responsible officials and planned corrective actions Management will put in place controls and procedures to annually evaluate the percentage of time staff dedicate to the organization to determine the correct allocation for payroll.

View Audit 36851

Finding 34537 (2022-004)

Material Weakness 2022

Vista Homes Housing Corporation

NY

HUD Housing Programs Special Tests & Provisions Cash Management

Reporting views of responsible officials and planned corrective actions Management will open a new residual account for this HUD entity and will put controls in place to ensure that the calculated surplus cash balance is deposited into the account, if applicable, annually.

View Audit 36851

Finding 34536 (2022-003)

Material Weakness 2022

Vista Homes Housing Corporation

NY

Reporting Internal Control / Segregation of Duties Material Weakness

Reporting views of responsible officials and planned corrective actions Management will put in place controls and procedures to ensure financial reporting is complete, accurate, and timely.

View Audit 36851

Finding 34535 (2022-002)

Material Weakness 2022

Vista Homes Housing Corporation

NY

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Reporting views of responsible officials and planned corrective actions Management has put in place controls and procedures to ensure that funds are not over-disbursed in the future. Management will return the funds to the HUD entity.

View Audit 36851 Questioned Costs: $1

Finding 34534 (2022-001)

Material Weakness 2022

Vista Homes Housing Corporation

NY

HUD Housing Programs Special Tests & Provisions Cash Management

Reporting views of responsible officials and planned corrective actions Management will ensure that security deposits are tracked so they can be recorded accordingly when there is a move in and/or move out. Moving forward management will put in place controls to ensure that the calculation is done a...

Reporting views of responsible officials and planned corrective actions Management will ensure that security deposits are tracked so they can be recorded accordingly when there is a move in and/or move out. Moving forward management will put in place controls to ensure that the calculation is done at the end of the fiscal year.

View Audit 36851

Finding 34531 (2022-007)

Material Weakness 2022

Vista Homes Housing Corporation

NY

Eligibility HUD Housing Programs Material Weakness

Reporting views of responsible officials and planned corrective actions Management will put controls and procedures in place that ensure all tenant files are maintained in accordance with the HUD Handbook.

View Audit 36851

Finding 34530 (2022-006)

Material Weakness 2022

Vista Homes Housing Corporation

NY

Allowable Costs / Cost Principles HUD Housing Programs Material Weakness

Reporting views of responsible officials and planned corrective actions Management will ensure that moving forward there are controls in place to ensure expenses are captured in the correct fiscal period and that at year end there is a final review of the transactions to ensure that everything is no...

Reporting views of responsible officials and planned corrective actions Management will ensure that moving forward there are controls in place to ensure expenses are captured in the correct fiscal period and that at year end there is a final review of the transactions to ensure that everything is not only properly entered, but properly classified as well.

View Audit 36851

Finding 34526 (2022-002)

Material Weakness 2022

Town of Clarksville

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

FINDING 2022-002 Contact Person Responsible for Corrective Action: Sherry Lockard Contact Phone Number: 812-283-1500 Views of Responsible Official: The Town concurs with the finding. Description of Corrective Action Plan: The Town has assigned the duties to request reimbursement (LPA Invoice Voucher...

FINDING 2022-002 Contact Person Responsible for Corrective Action: Sherry Lockard Contact Phone Number: 812-283-1500 Views of Responsible Official: The Town concurs with the finding. Description of Corrective Action Plan: The Town has assigned the duties to request reimbursement (LPA Invoice Voucher) from the IN Dept of Transportation to the Office Manager of Public Works. The Office Manager will prepare the LPA Invoice Voucher for INDOT and one of the two ERC?s, Public Works Director, or Assistant Public Works Director, will review for accuracy and sign off on the LPA Invoice Voucher. Anticipated Completion Date: May 9, 2023

View Audit 35793

Finding 34523 (2022-003)

Material Weakness 2022

Monroe Fire Protection District

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.303

FINDING 2022-003 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We understand and agree with the importance of internal controls and segregation of d...

FINDING 2022-003 Subject: Staffing for Adequate Fire and Emergency Response (SAFER) Contact Person Responsible for Corrective Action: Dustin Dillard Contact Phone Number: 812-331-1906 Views of Responsible Official: We understand and agree with the importance of internal controls and segregation of duties at the District and we believe our policies, procedures, individual job descriptions and management oversight fulfill these necessary requirements, we intend to comply with the suggestions made by the auditing staff. Description of Corrective Action Plan: The SAFER Reimbursement Request spreadsheets are prepared by two administrative personnel who perform checks and balances on calculations, payroll reports, time-keeping reports and employee roster changes before submitting the information to the Fire Chief for review and submission. The District now requires both Administrative personnel to sign and date a cover sheet upon completion of the compilation. The Financial Administrative Assistant will reconcile the data entered into the FEMA portal by the Chief by initialing a printed copy of the dated request. Anticipated Completion Date: To be implemented with all future reimbursement requests following this date 8-23-23 More information about this finding is available in the Supplemental Report.

View Audit 32668

Finding 34492 (2022-102)

Material Weakness 2022

City of Parker, Florida

FL

Matching / Level of Effort / Earmarking Subrecipient Monitoring Material Weakness § 200.303

Financial Statement Finding Number: 2022-102 Lack of Documented Review of Required Quarterly Reports Planned Corrective Action: The City implemented procedures to document review of reports for accuracy and to make sure reports are completed in a timely manner prior to submission. Throughout the ye...

Financial Statement Finding Number: 2022-102 Lack of Documented Review of Required Quarterly Reports Planned Corrective Action: The City implemented procedures to document review of reports for accuracy and to make sure reports are completed in a timely manner prior to submission. Throughout the year the public works assistant input percent of completion of projects into excel spreadsheet which was reviewed by the public works director prior to providing the information to the third-party grant manager for upload to the grant portal but the review by the City was not documented. Going forward, the spreadsheet will continue to be prepared by the public works assistant then sent to public works director for approval and signature prior to providing the spreadsheet to the third party grant manager for submission to the State. Anticipated Completion Date: 09/30/2023 Responsible Contact Person: Taylor Jeffreys, Public Works Assistant

View Audit 32267

Finding 34491 (2022-101)

Material Weakness 2022

City of Parker, Florida

FL

Questioned Costs Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

Financial Statement Finding Number: 2022-101 Lack of Documented Review of Reimbursement Requests Planned Corrective Action: This finding was identified during the 2020 audit which was not issued until February of 2022. Once issued, the City implemented new procedures where the Florida Public Assis...

Financial Statement Finding Number: 2022-101 Lack of Documented Review of Reimbursement Requests Planned Corrective Action: This finding was identified during the 2020 audit which was not issued until February of 2022. Once issued, the City implemented new procedures where the Florida Public Assistance website sends an email to request approval of reimbursements. The public work director and public works assistant both approve the reimbursement. The public works assistant then uploads reimbursement into Florida Public Assistance website and signs electronically for reimbursement to document review and approval by the City of the reimbursement request. Anticipated Completion Date: 09/30/2023 Responsible Contact Person: Taylor Jeffreys, Public Works Assistant

View Audit 32267 Questioned Costs: $1

Finding 34455 (2022-001)

Material Weakness 2022

Marian University

IN

Material Weakness Reporting

Audit Finding Number 2022-001 Program COVID-19 - Education Stabilization Funds ? American Rescue Plan Act (ARPA) Federal Assistance Listing Number 84.425E and 84.425F Federal Grantor U.S. Department of Education Views of Responsible Officials We recognize that the filing of certain required reports ...

Audit Finding Number 2022-001 Program COVID-19 - Education Stabilization Funds ? American Rescue Plan Act (ARPA) Federal Assistance Listing Number 84.425E and 84.425F Federal Grantor U.S. Department of Education Views of Responsible Officials We recognize that the filing of certain required reports did not meet all established requirements. We believe this resulted because the task for these filings was not appropriately transferred upon a change in management roles. Planned Corrective Action For future federal award programs, the individual assigned responsibility for reporting will create a summary of the required reports and deadlines. That report will be shared with their supervisor so that it can be passed along in the situation of a change in management roles. Anticipated Completion Date December 31, 2022 Responsible Contact Person Michael Bedel, Assistant Vice President of Finance and Accounting Contact Information 317-955-6009

View Audit 30960

Finding 34450 (2022-001)

Material Weakness 2022

American Academy McAllister Institute of Funeral Service, Inc.

NY

Reporting Material Weakness

Recommendation: The auditors recommended that the Institute implement a formal policy for preparing the SEFA and reconciling the SEFA for accuracy and completeness to underlying accounting records. Action Taken: We agree with both the finding and the recommendation. The amount reflected in the year...

Recommendation: The auditors recommended that the Institute implement a formal policy for preparing the SEFA and reconciling the SEFA for accuracy and completeness to underlying accounting records. Action Taken: We agree with both the finding and the recommendation. The amount reflected in the year ended September 30,2021 SEFA was misstated due to an incorrect interpretation as to the amount to be reported as an accrual of HEERF expenditures under the Uniform Guidance for SEFA reporting. The correct amount of HEERF expenditures were included in the GAAP financial year ended September 30,2021 financial statements. HERRF expenditures for the year ended September 30,2022 were reported correctly in both the SEFA report and the GAAP financial statements.

View Audit 30410

Finding 34445 (2022-001)

Material Weakness 2022

Housing Authority of the City of Laurens

SC

HUD Housing Programs Eligibility Material Weakness

2022-001 - Eligibility: Public Housing Tenant Files Material Weakness in Internal Control, Material Noncompliance Condition: Out of a total tenant population of 120, 12 files were selected for testing. Exceptions were noted as follows: ? 6 files where the annual re-examination was not performed...

2022-001 - Eligibility: Public Housing Tenant Files Material Weakness in Internal Control, Material Noncompliance Condition: Out of a total tenant population of 120, 12 files were selected for testing. Exceptions were noted as follows: ? 6 files where the annual re-examination was not performed within 12 months. ? 2 files where the annual income for the tenant was not calculated correctly, resulting in the monthly rent for the tenant being $204 too low in one case and $23 too low in the other. Recommendation: The above-mentioned change will only result in non-timely annual re-examinations for some tenants for one time, and will effectively correct itself in future years. Nonetheless, the Authority should review all annual re-examinations for all tenants and immediately perform annual re-examinations for any remaining tenants that have not already had their next re-examination Action Taken: The Authority concurs with this finding and has begun a review of all files to identify any remaining tenants that have not had a timely annual re-examination and to immediately conduct any needed re-examinations. Effective Date: June 12, 2023 Contact Information Brian Griswell, Executive Director Housing Authority of the City of Laurens 218 Spring Street Laurens, SC 29360 (864) 984-6568

View Audit 36899

Finding 34422 (2022-001)

Material Weakness 2022

Oregon Shakespeare Festival Association, Inc.

OR

Reporting Internal Control / Segregation of Duties Material Weakness

We have pre-emptively been on a path to remedy these problems. Our actions include: ?Transaction processing and key account reconciliations are up to date as of 7/1/2023. ?Development of controls over review processes began in March of 2023 ?Implementation of new and modified procedures to enhance t...

We have pre-emptively been on a path to remedy these problems. Our actions include: ?Transaction processing and key account reconciliations are up to date as of 7/1/2023. ?Development of controls over review processes began in March of 2023 ?Implementation of new and modified procedures to enhance the control environment is on-going as department functionality is reviewed and changed. This includes control & oversight established over our material subledgers this calendar year. ?Monthly closings, including financial reporting, are in development and scheduled to start before the end of the fiscal year 10/31/2023. ?To achieve compliance OSF: ?Hired qualified accounting contractors to perform timely and accurate entries in our financial system of record beginning January 2023. ?Hired an Interim Executive Director, Tyler Hokama, with executive experience at multiple Fortune 500 companies on June 1, 2023. The Interim Executive Director is currently filling permanent, qualified Finance/Accounting roles within the organization, securing professional knowledge and actively overseeing the stabilization of Finance systems and processes. Anticipated Completion Date: October 31, 2023

View Audit 33127

Finding 34387 (2022-001)

Material Weakness 2022

Columbia International University and Subsidiaries

SC

Student Financial Aid Material Weakness Reporting

Finding Number: 2022-001 Untimely Returns of Title IV Funds and Inaccurate Returns of Title IV Funds (R2T4) Planned Corrective Action: Three of the four students with inaccurate return of Title IV fund calculations were corrected during the audit. FA Office is in the process of reaching out to the...

Finding Number: 2022-001 Untimely Returns of Title IV Funds and Inaccurate Returns of Title IV Funds (R2T4) Planned Corrective Action: Three of the four students with inaccurate return of Title IV fund calculations were corrected during the audit. FA Office is in the process of reaching out to the student with an over-return of $418 in FDL for authorization to disburse this amount. FA Office has met with Assistant Registrar for Online Studies and Academic Advising to review the federal regulations for R2T4 in modular programs. The Online Advising and Registrar team were provided with a list of module withdrawal questions that should help to determine if a student is a withdrawal. A copy of questions that were provided to those teams is attached. The following procedures were established between both offices to eliminate untimely and inaccurate return of Title IV funds going forward: If a student is dropped for inactivity/nonparticipation, the remainder of their courses for that payment period are dropped as well. This allows the return of unearned Title IV funds to be completed no later than 45 days after the school determines the LDA. If a student would like to take a break and return to a module that begins later in the payment period, they must provide a statement of intent to return (written confirmation) and the module must begin no later than 45 calendar days after the end of the module the student ceased attending. Financial Aid also met with Associate Registrar and CIU Database Developer to create a report that better captures students who are determined as withdrawals in modular programs. This will assist in monitoring the online student population and achieve more accuracy in reporting. Online Financial Aid team has redistributed workload so that the Associate Director has more time designated to monitor and oversee the R2T4 process. Person Responsible for Corrective Action Plan: Patty Hix, Director of Financial Aid and Lynsay Shumpert, Associate Director for Online Studies Anticipated Date of Completion: Report has been created and we are in the testing phase.

View Audit 30211

Corrective Action Plans

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