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Corrective Action Plans

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Finding 554299 (2024-001)
Significant Deficiency 2024
City of San Bruno
CA
Questioned Costs Reporting Significant Deficiency
The City will develop, document, and implement a formal year-end closing process and audit preparedness policy and procedures. The responsibilities, deliverables, and deadlines will be clearly outlined and communicated to all staff members. The City remedied the delinquent ARPA SLFRF quarterly P&E R...
The City will develop, document, and implement a formal year-end closing process and audit preparedness policy and procedures. The responsibilities, deliverables, and deadlines will be clearly outlined and communicated to all staff members. The City remedied the delinquent ARPA SLFRF quarterly P&E Report to the Treasury in January 2024, covering July 1, 2022, through December 31, 2023. Management intends to fully expend the remaining ARPA SLFRF award in FY24 and file the required quarterly P&E Reports in April 2024 and the final report in July 2024.
View Audit 352902
Finding 554289 (2024-002)
Significant Deficiency 2024
City of Satellite Beach
FL
Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Recommendation: Review of reports should be documented prior to submission to the grantor. Management Response: The City has worked and will continue to work diligently on this issue. The City is working to ensure that all reports are properly reviewed prior to submission and that evidence of the re...
Recommendation: Review of reports should be documented prior to submission to the grantor. Management Response: The City has worked and will continue to work diligently on this issue. The City is working to ensure that all reports are properly reviewed prior to submission and that evidence of the review process is properly documented. Responsible Parties: Brittany Retherford, City Manager, Nick Walsh, Comptroller, and Mindy Brown, Assistant Comptroller Anticipated Completion Date: September 30, 2025
View Audit 352895
Finding 554287 (2024-003)
Significant Deficiency 2024
City of West Melbourne, Florida
FL
Questioned Costs HUD Housing Programs Reporting § 200.303
Recommendation: The City should create a process to alert/remind management and City officials to meet the reporting requirements and deadlines. Corrective Action: The City recognizes the need for timely grant reporting and has recently added a Grants Administrator position to the Finance Department...
Recommendation: The City should create a process to alert/remind management and City officials to meet the reporting requirements and deadlines. Corrective Action: The City recognizes the need for timely grant reporting and has recently added a Grants Administrator position to the Finance Department who has created a grant report tracking process. Responsible Parties: Candice Blake, Finance Director Anticipated Completion Date: September 30, 2025
View Audit 352892
Hickory Lane One, INC
MD
Questioned Costs HUD Housing Programs Cash Management
The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits.
The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits.
View Audit 352863 Questioned Costs: $1
Hickory Lane One, INC
MD
Questioned Costs HUD Housing Programs
The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits.
The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits.
View Audit 352863 Questioned Costs: $1
Luther Crest, INC
KS
Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs
Finding 2024-001: During the year ended December 31 2024 reserve deposits totaling $45256 were not made as required by the regulatory agreement (1) Comments on the Finding and Each Recommendation: The Organization did not have sufficient cash flow to make the required deposits. The management agent ...
Finding 2024-001: During the year ended December 31 2024 reserve deposits totaling $45256 were not made as required by the regulatory agreement (1) Comments on the Finding and Each Recommendation: The Organization did not have sufficient cash flow to make the required deposits. The management agent has reflected the delinquent reserve payments as payable at December 31 2024 and is making deposits as cash flow allows; (2) Actions Taken on the Finding: The Organization obtained a 6 month suspension of deposits and is making the delinquent deposits as cash flow allows
View Audit 352857 Questioned Costs: $1
Luther Knoll INC
KS
Questioned Costs HUD Housing Programs Reporting
Finding 2024-001: During the year ended December 31 2024 reserve deposits totaling $9000 were not made as required by the regulatory agreement. (1) Comments on the Finding and Each Recommendation: The Organization did not have sufficient cash flow to make the required deposits. The management agent ...
Finding 2024-001: During the year ended December 31 2024 reserve deposits totaling $9000 were not made as required by the regulatory agreement. (1) Comments on the Finding and Each Recommendation: The Organization did not have sufficient cash flow to make the required deposits. The management agent has reflected the delinquent reserve payments as a payable at December 31 2024 and is making deposits as cash flow allows. (2) Actions Taken on the Finding: The Organization is making the delinquent depoist as cash flow allows
View Audit 352855 Questioned Costs: $1
Finding 554280 (2024-002)
Significant Deficiency 2024
City of Amarillo, Texas
TX
Questioned Costs Reporting
Condition: Retainage payable of $47,878 was incorrectly reported in the program expenditures as of September 30, 2024. Corrective Action Plan: See the City’s response starting on page 19.
Condition: Retainage payable of $47,878 was incorrectly reported in the program expenditures as of September 30, 2024. Corrective Action Plan: See the City’s response starting on page 19.
View Audit 352851
Finding 554236 (2024-001)
Significant Deficiency 2024
Rsu/msad No. 29
ME
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) 2024-001 – Wage Rate Requirements Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 will take the following actions to address finding 2023-001: The district has been implementing n...
CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) 2024-001 – Wage Rate Requirements Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 will take the following actions to address finding 2023-001: The district has been implementing new procedures and processes as of May 15, 2024, to correct the issues in question to comply with CFR(s): 2 CFR Appendix II to Part 200; 29 CFR 5.2; 29 CFR 5.5, to make sure we remain in compliance with OMB guidelines. As originally addressed in the Corrective Action Plan, back wages have been issued to ensure compliance with federal guidelines and language has been incorporated into new construction contracts and documents. Davis Bacon language has been included in current year construction projects paid with federal and/or state funding. Payroll certifications have been received and reviewed with each invoice submitted for payment by the district’s business manager to ensure compliance with wage rate requirements for Davis Bacon guidelines as applicable. A copy of the OMB Circulars containing the CFR guidelines have been received and reviewed by the Business Manager and applicable grant managers/coordinators to implement a more stringent internal control process and procedure to ensure all requirements are followed. The Business Manager has updated the district’s administrative team and central office staff of applicable guidelines to ensure compliance of all projects that is being paid for by federal and/or state funding. Anticipated Completion Date: October 15, 2024
View Audit 352806
Finding 554198 (2024-003)
Significant Deficiency 2024
Crossnore Communities for Children
NC
Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles § 200.430
Recommendation: During our review of the grant expenditures, it was noted that budgeted amounts were charged to the grant instead of the actual costs incurred. This practice was observed in multiple instances, leading to discrepancies between the reported expenditures and the actual costs. Managemen...
Recommendation: During our review of the grant expenditures, it was noted that budgeted amounts were charged to the grant instead of the actual costs incurred. This practice was observed in multiple instances, leading to discrepancies between the reported expenditures and the actual costs. Management did not review time and effort to make after-the-fact adjustments to the amounts charged to the grant. We recommend that the Organization establish a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has established a review process to ensure that all costs charged to the grant are based on actual expenditures and are properly documented. Name(s) of the contact person(s) responsible for corrective action: Theresa Watters Planned completion date for corrective action plan: February 21, 2025
View Audit 352789
Finding 554197 (2024-002)
Significant Deficiency 2024
Crossnore Communities for Children
NC
Questioned Costs Allowable Costs / Cost Principles Cash Management
Recommendation: Under 2 CRF 200.406, credits accruing to or received by the recipient of federal funding that relate to allowable costs must be credited to the Federal award as either a cost reduction or cash refund. The Organization did not have adequate internal controls designed to properly deter...
Recommendation: Under 2 CRF 200.406, credits accruing to or received by the recipient of federal funding that relate to allowable costs must be credited to the Federal award as either a cost reduction or cash refund. The Organization did not have adequate internal controls designed to properly determine the appropriate amounts to be submitted for reimbursement. We recommend the Organization review the expenditures submitted to SAMHSA and ensure that there is no "double dipping' of sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a review process for all expenditures submitted to SAMHSA. The review process ensures that there is no “double dipping” of sales tax. Name(s) of the contact person(s) responsible for corrective action: Theresa Watters Planned completion date for corrective action plan: February 21, 2025
View Audit 352789
Santa Fe Recovery Center, Inc.
NM
Questioned Costs Reporting Special Tests & Provisions § 200.512
Corrective action plan: Management has implemented correction of this finding, after education as to deadlines for submission of the completed audit report. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer. Estimated corrective action completion date: Apri...
Corrective action plan: Management has implemented correction of this finding, after education as to deadlines for submission of the completed audit report. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer. Estimated corrective action completion date: April 2025
View Audit 352776
Finding 554154 (2024-004)
Significant Deficiency 2024
Santa Fe Recovery Center, Inc.
NM
Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403 § 200.430
Corrective action plan: Management is in the process of implementing a method for employees to charge their time to grants, as needed, from the payroll system. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer. Estimated corrective action completion date: M...
Corrective action plan: Management is in the process of implementing a method for employees to charge their time to grants, as needed, from the payroll system. Personnel responsible for corrective action: Timothy Jodway, Interim Chief Financial Officer. Estimated corrective action completion date: May 2025
View Audit 352776 Questioned Costs: $1
Red River Valley Community Action
ND
Questioned Costs
Contact Person Jacqueline Hasset Corrective Action Plan Management agrees with the recommendation and will continue to look for low-income representative board members. Completion Date Red River Valley Community Action will implement the plan in 2025.
Contact Person Jacqueline Hasset Corrective Action Plan Management agrees with the recommendation and will continue to look for low-income representative board members. Completion Date Red River Valley Community Action will implement the plan in 2025.
View Audit 352759
Finding 554089 (2024-001)
Material Weakness 2024
Town of Brunswick Maine
ME
Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.430
Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. ...
Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.
View Audit 352733 Questioned Costs: $1
Town of Brunswick Maine
ME
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Management Response/Corrective Action Plan: We have had a lot of turnover in the business office with a new finance director, payroll coordinator, and finance accounts coordinator (bookkeeper). Since being notified of the issue, we have put procedures in place to ensure issues related to MainePERS ...
Management Response/Corrective Action Plan: We have had a lot of turnover in the business office with a new finance director, payroll coordinator, and finance accounts coordinator (bookkeeper). Since being notified of the issue, we have put procedures in place to ensure issues related to MainePERS contributions do not occur and/or are resolved in a timely manner. As employees are hired, or change funding accounts, the payroll coordinator now has procedures in place to check the appropriate deductions for each account. We also are up to date with MainePERS reconciliation, which includes reviewing contributions for federally funded employees. If an error occurs, the process will cause us to review the issue and reconcile the accounts as necessary.
View Audit 352733 Questioned Costs: $1
Finding 554080 (2024-002)
Significant Deficiency 2024
Town of Brunswick Maine
ME
Allowable Costs / Cost Principles Questioned Costs Matching / Level of Effort / Earmarking § 200.430
Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. ...
Management Response/Corrective Action Plan: The School Department completed the necessary time and effort documents for expense reimbursement that were approved by the Department of Education. The time and effort was not specific to actual time worked for those split among multiple grants or funds. Moving forward, any employee who has time split between multiple grants or Federal and non-Federal activities will be expected to complete a personnel activity report. This report will record actual time spent working on eligible activities for each fund. If the employee has a regular schedule, the employee’s schedule will suffice as their personnel activity report, as long as it follows the guidelines. The personnel activity reports will be requested each month during the reimbursement request process and will be signed by the employee and their supervisor.
View Audit 352733 Questioned Costs: $1
Finding 554078 (2024-001)
Significant Deficiency 2024
M.s.a.d. No 70
ME
Allowable Costs / Cost Principles Questioned Costs § 200.303 § 200.430
CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Catrina Kemp, Business Manager Corrective Action: The Regional School Unit No. 70 will take the following actions to address finding 2024-001. Managerment will review standards and requirements ann...
CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Catrina Kemp, Business Manager Corrective Action: The Regional School Unit No. 70 will take the following actions to address finding 2024-001. Managerment will review standards and requirements annually to ensure that the district is following federal guidelines. Management will also employ a signature and date on all federal grant disbursements to ensure that all criteria and requirements are met. Allowable costs will be assesed monthly before submission for allowability. Management will implement a two step review process for contracts and payroll. Anticipated Completions Date: July 1, 2025
View Audit 352732
East-West University
IL
Special Tests & Provisions Questioned Costs Student Financial Aid
2024-001: Return of Title IV - Student Financial Aid Cluster - Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2024 Condition: During our return of Title IV Fund testing we noted that University did not properly calculate or return Title IV for one st...
2024-001: Return of Title IV - Student Financial Aid Cluster - Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended August 31, 2024 Condition: During our return of Title IV Fund testing we noted that University did not properly calculate or return Title IV for one student out of the five students in our sample. The University returned $687 more in Title IV funds than they were required to return. We consider this to be an instance of non-compliance relating to the Special Tests and Provisions Compliance Requirement. Corrective Action Plan Financial Aid Office will make sure to accurate calculate the return of Title IV. EWU will return the over awarded Direct Loan Subsidized to reflect the correct amount for the student. This was an isolated data entry error while entering the amounts on COD R2T4 calculator. Responsible Person for Corrective Action Plan Director of Financial Aid Cesar Campos Implementation Date of Corrective Action Plan 02/10/2025
View Audit 352724
Nbc-Usa, Housing, Inc., Thirteen
OH
Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations The Corporation concurs and was able to obtain the UEI in order to complete and submit the 2022 and 2023 data collection forms. S3800-130 Response Indicator Agree S3800-140 Completion Date November 25, 2024 S38...
S3800-090 Auditor's Summary of the Auditee's Comments on the Findings and Recommendations The Corporation concurs and was able to obtain the UEI in order to complete and submit the 2022 and 2023 data collection forms. S3800-130 Response Indicator Agree S3800-140 Completion Date November 25, 2024 S3800-150 Response N/A S3800-160 Contact Person First Name Jill S3800-180 Contact Person Last Name Kolb
View Audit 352658
Finding 554027 (2024-007)
Material Weakness 2024
Inglewood Unified School District
CA
Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.430
The District acknowledges this finding and is committed to strengthening internal controls to ensure compliance with federal time accounting requirements. The State and Federal Programs Department has received training on Time and Effort procedures, and additionally training is being provided to sch...
The District acknowledges this finding and is committed to strengthening internal controls to ensure compliance with federal time accounting requirements. The State and Federal Programs Department has received training on Time and Effort procedures, and additionally training is being provided to school sites to reinforce accurate time certification and documentation for federal fund expenditures. To address the deficiencies, the district will shift from an annual to a monthly reconciliation process, ensuring that employee salaries charged to Title I accurately reflect actual work performed. The State and Federal Programs Department will collaborate with the Budget Department to systematically track employees funded through Title I and verify that all required PARs are completed and maintained.
View Audit 352638 Questioned Costs: $1
Finding 554026 (2024-006)
Material Weakness 2024
Inglewood Unified School District
CA
Questioned Costs Reporting Internal Control / Segregation of Duties
The District acknowledges this finding and is committed to strengthening controls over graduation cohort documentation. To address this, we will provide targeted training for school site staff on proper cohort coding, allowable documentation, and compliance requirements. Additionally, we will implem...
The District acknowledges this finding and is committed to strengthening controls over graduation cohort documentation. To address this, we will provide targeted training for school site staff on proper cohort coding, allowable documentation, and compliance requirements. Additionally, we will implement a standardized review process to ensure that all student cohort removals have appropiate supporting records and are retained in a centralilzed system for audit purposes. To further enhance compliance, the District will conduct periodic internal audits to verify accuracy of past and future cohort removals, updating records as necessary. Clear procedural guidelines will be established, and a designated compliance team will oversee adherence to these protocols. These corrective actions will ensure accurate graduation reporting and prevent the recurrence of this issue.
View Audit 352638 Questioned Costs: $1
Finding 553977 (2024-004)
Material Weakness 2024
Desert Aids Project, Inc.
CA
Questioned Costs Special Tests & Provisions Eligibility
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Special Tests and Provision – Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary Health centers must prepare and apply a sliding f...
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Special Tests and Provision – Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary Health centers must prepare and apply a sliding fee discount schedule (Sliding Fee Discounts) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Internal controls in place did not ensure that the sliding fee discount was not given until all income verification was obtained. Or in cases where the sliding fee discount was given pending income verification, the income verification was not completed which resulted in sliding fee discounts being given without adequate support. Responsible Individuals Nedy Terrazas, Assoc COO, Simon Bahta, EPIC EHR Mgr and Briana Renner, CFO Status Management of DAP Health, Inc. has policies and procedures in place which require the completion of the income verification and obtaining the necessary information for the sliding fee discount prior to a sliding fee discount being given. However, with the acquisition of the new clinics, the policies and procedures already in place were not being followed appropriately at all clinics. Management has had staff complete additional training and provided education to explain why the sliding fee discounts cannot be given until a completed file, including income verification support, is obtained. Anticipated Completion Date June 30, 2025
View Audit 352630 Questioned Costs: $1
Finding 553975 (2024-003)
Material Weakness 2024
Desert Aids Project, Inc.
CA
Questioned Costs Allowable Costs / Cost Principles Material Weakness
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP...
Department of Housing and Urban Development Federal Financial Assistance Listing #93.224 and #93.527 Community Health Center Cluster Reporting – Material Weakness in Internal Control over Compliance Finding Summary Certain tables within the Universal Data System (UDS) Report did not reconcile to DAP Health, Inc. supporting information. The tables that did not reconcile to the supporting information include Table 4, Selected Patient Characteristics, and Table 5, Staffing and Utilization. Table 4 reports the total number of patients seen while Table 5 reports the number of clinic visits by the various types of providers. The primary causes of the differences were due to DAP Health, Inc. acquiring a large entity during the year which used a different Electronic Health Record System. The combination of bringing together information from two different systems caused the reporting to be more complicated. In addition, certain supporting documentation used to prepare the UDS report was not maintained. The review process for the UDS report was also not functioning properly. Responsible Individuals Rigo Garcia, Analytics Manager and Bill Lee, Director of Information Management Status Management of DAP Health, Inc. has already converted the 25 acquired clinics to the DAP Health, Inc. Electronic Health System, which streamlined the process for the preparation of the UDS Report for the calendar year ending December 31, 2024. In addition, management has implemented new procedures requiring supporting documentation to be maintained. Management has also implemented a formalized review procedure for the UDS Report prior to submission. Anticipated Completion Date March 31, 2025
View Audit 352630
Finding 553974 (2024-002)
Material Weakness 2024
Desert Aids Project, Inc.
CA
Questioned Costs HUD Housing Programs Material Weakness
Department of Housing and Urban Development Federal Financial Assistance Listing #14,421 Housing Opportunities for Person with AIDS (HOPWA) Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary Internal controls were not in place to ensure that ...
Department of Housing and Urban Development Federal Financial Assistance Listing #14,421 Housing Opportunities for Person with AIDS (HOPWA) Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary Internal controls were not in place to ensure that the monthly expenditure information that was summarized and used to prepare the Consolidate Annual Performance and Evaluation Report (Consolidated APR/CAPER) was reconciled to the general ledger which led to differences between the expenditures reported in the Consolidated APR/CAPER and the actual expenditures reflected in the general ledger. In addition, internal controls were not in place to ensure review of the supporting documentation and the Consolidated APR/CAPER prior to submission. Responsible Individuals Monica Atchison, Housing Manager, and JW Guay, Grants Accounting Manager Status Management of DAP Health, Inc. has already corrected the reports and submitted updated reports to the granting agency. We have also implemented additional procedures to review program required reporting between Program and Finance Leadership to ensure amounts reported reconcile to the general ledger prior to submission. Anticipated Completion Date March 31, 2025
View Audit 352630
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