Corrective Action Plans

Finding 1191814 (2023-002)

Material Weakness 2023

IL

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Finding 2023-002: Grant Administration Condition: During our current year-end audit procedures, we noted that the County did not have adequate centralized procedures to track, monitor, and aggregate grant activity across grant departments to ensure compliance with grant requirements and to identify ...

Finding 2023-002: Grant Administration Condition: During our current year-end audit procedures, we noted that the County did not have adequate centralized procedures to track, monitor, and aggregate grant activity across grant departments to ensure compliance with grant requirements and to identify when the Single Audit threshold was met. .Plan: The County will designate a central function, such as the Treasurer's Office, to maintain a comprehensive list of all grants awards received by County Departments. Departments will be required to notify the central function upon application for and receipt of grant funding and to provide periodic expenditure and compliance information. Standardized procedures will be implemented to monitor grant activity, track cumulative federal expenditures, and assess Single Audit applicability. Anticipated Date of Completion: Audit for Fiscal Year Ended November 30, 2024 Name of Contact Person: Erica Firnhaber, County Treasurer ', l Management Response: Management acknowledges this finding and will work to correct it by the anticipated date identified above.

View Audit 395638

Finding 1191756 (2023-005)

Material Weakness 2023

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Questioned Costs Material Weakness Reporting

2022-005 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, 2026

View Audit 395557

Finding 1182642 (2023-001)

Material Weakness 2023

Country Club Hills School District 160

IL

Questioned Costs

The District will implement a process to track the submission time of the data collection form and audit package.

View Audit 394087

Finding 1182551 (2023-002)

Material Weakness 2023

Sheepscot Valley Regional School Unit No. 12

ME

Questioned Costs Procurement, Suspension & Debarment

Management’s Response/Corrective Action Plan: The Superintendent and Business Manager will formally review all applicable procedures with the administrative team. The administrative team will ensure that consistent training is provided to their respective Administrative Assistants. The Business Mana...

Management’s Response/Corrective Action Plan: The Superintendent and Business Manager will formally review all applicable procedures with the administrative team. The administrative team will ensure that consistent training is provided to their respective Administrative Assistants. The Business Manager will conduct periodic follow-up reviews with the Administrative Assistants to monitor compliance and reinforce procedures. In addition, the Business Manager will review purchasing procedures with the Accounts Payable Clerk to ensure that no supplies are ordered without an approved purchase order.

View Audit 393990

Finding 1182223 (2023-006)

Material Weakness 2023

Independent Resources, Inc.

DE

Allowable Costs / Cost Principles Period of Performance Questioned Costs

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop and implement formal written policies and procedures to strengthen internal controls over monitoring the period of performance for all federal awards. In addition, manage...

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop and implement formal written policies and procedures to strengthen internal controls over monitoring the period of performance for all federal awards. In addition, management will provide training to relevant staff on federal grant compliance requirements related to allowable costs and period of performance to ensure expenditures are incurred within the authorized timeframe.

View Audit 393606

Finding 1182222 (2023-005)

Material Weakness 2023

Independent Resources, Inc.

DE

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that the timely filing of the annual reports to ensure proper program compliance. Proposed Completion Date September 30, 2026

View Audit 393606

Finding 1182221 (2023-004)

Material Weakness 2023

Independent Resources, Inc.

DE

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that proper internal control procedures and expenditure approval forms are filled out. Proposed Completion Date September 30, 2026

View Audit 393606

Finding 1182220 (2023-003)

Material Weakness 2023

Independent Resources, Inc.

DE

Questioned Costs

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that the timely filing of its single audit report to the Federal Audit Clearinghouse. Proposed Completion Date September 30, 2026

View Audit 393606

Finding 1182219 (2023-002)

Material Weakness 2023

Independent Resources, Inc.

DE

Questioned Costs Internal Control / Segregation of Duties

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will take steps to recruit additional Board members and schedule meetings in accordance with the by-laws. In addition, the Organization will consider amending its by-laws to reflect t...

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will take steps to recruit additional Board members and schedule meetings in accordance with the by-laws. In addition, the Organization will consider amending its by-laws to reflect the Organization’s current operational capacity while still ensuring adequate governance. Proposed Completion Date September 30, 2026

View Audit 393606

Finding 1182218 (2023-001)

Material Weakness 2023

Independent Resources, Inc.

DE

Internal Control / Segregation of Duties Questioned Costs Reporting

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization has created a policy surrounding the issuance of bonuses. Bonuses may include performance-based, project-specific, and discretionary categories. The Executive Director initiates bonus...

Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization has created a policy surrounding the issuance of bonuses. Bonuses may include performance-based, project-specific, and discretionary categories. The Executive Director initiates bonuses, while the Board of Directors provides final approval, maintaining transparency throughout. Regular reviews and audits ensure fairness and compliance. Non-compliance consequences are outlined. This policy emphasizes open communication, promoting a culture of fairness, accountability, and recognition of employee contributions. Proposed Completion Date September 30, 2026

View Audit 393606

Finding 1181799 (2023-003)

Material Weakness 2023

145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION

NY

HUD Housing Programs Questioned Costs

Management has reviewed the circumstances surrounding this finding and confirmed that, based on the January 2024 tenant lease, the security deposit had already been refunded to the tenant. To prevent future noncompliance, management will implement the following measures: • Strengthen internal proced...

Management has reviewed the circumstances surrounding this finding and confirmed that, based on the January 2024 tenant lease, the security deposit had already been refunded to the tenant. To prevent future noncompliance, management will implement the following measures: • Strengthen internal procedures to ensure all security deposit refunds or itemized charge statements are issued within the required HUD timeframes. • Maintain clear documentation in each tenant file verifying the date of refund or the date the itemized list of charges was provided. • Conduct periodic internal file reviews to ensure ongoing compliance with HUD occupancy requirements. • Provide staff training on HUD regulations related to security deposit processing and documentation standards. These actions will ensure timely and compliant handling of security deposits going forward and prevent recurrence of this issue.

View Audit 393088

Finding 1181798 (2023-002)

Material Weakness 2023

145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION

NY

Eligibility HUD Housing Programs Questioned Costs

A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and iss...

A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.

View Audit 393088

Finding 1181797 (2023-001)

Material Weakness 2023

145 SO. 3RD STREET HOUSING DEVELOPMENT FUND CORPORATION

NY

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

1. Management will establish an administrative calendar of required filings for the submission of the single audit reporting package and data collection form. 2. A Single Audit reporting package and data collection form will be sent to the Federal Audit Clearinghouse (FAC) by the due date.

View Audit 393088

Finding 1181671 (2023-005)

Material Weakness 2023

Maryland Network Against Domestic Violence, INC

MD

Allowable Costs / Cost Principles Questioned Costs § 200.309 § 200.333 § 200.400

Summary of Findings During testing of program expenditures, one of thirty-seven expenditures (2.7%) tested was determined to be an unallowable cost under the grant. The amount identified totaled $13,247. This instance was identified as noncompliance with Allowable Costs/Cost Principles requirements....

Summary of Findings During testing of program expenditures, one of thirty-seven expenditures (2.7%) tested was determined to be an unallowable cost under the grant. The amount identified totaled $13,247. This instance was identified as noncompliance with Allowable Costs/Cost Principles requirements. The finding is not considered a repeated finding. Statistical sampling was not used in making sample selections. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-005. The administrative agent that administers the organization’s health insurance changed their name. As a result, the health insurance bill ($13,247.02) was coded to the wrong GL code. Instead of being posted to the health insurance expense code, this was erroneously posted to the GL code for other consultants. Corrective Action A. Immediate Corrective Action Taken 1. Management reviewed the specific expenditure and confirmed that it was erroneously assigned the wrong GL code. 2. The unallowable cost of $13,247 was removed from the federal award, and properly reclassified. 3. Supporting documentation of correction was retained. Completion Date: Completed prior to issuance of audited financial statements. B. Long-Term Corrective Actions The organization will develop a Vendor Change Monitoring Procedure that will require documentation and review when a vendor changes name, ownership, or payment structure. This will Include verification that the vendor is mapped to the correct GL account before payment is processed. Responsible Parties: Executive Director and Contractual Bookkeeper Completion Date: Within 60 days of the date of this memo.

View Audit 392932

Finding 1181664 (2023-008)

Material Weakness 2023

Maryland Network Against Domestic Violence, INC

MD

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles § 200.309

Summary of Findings Testing identified one expenditure out of seven sampled (14.3%) totaling $3,300 that was not recorded in the proper fiscal year. This was determined to be an instance of noncompliance in internal control over compliance related to Period of Performance requirements. The finding i...

Summary of Findings Testing identified one expenditure out of seven sampled (14.3%) totaling $3,300 that was not recorded in the proper fiscal year. This was determined to be an instance of noncompliance in internal control over compliance related to Period of Performance requirements. The finding is not considered a repeated finding. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-008. The organization failed to accurately review an expenditure that was billed in the audited fiscal year but was actually a prepay for services in the following fiscal year. The expenditure did appropriately fall within the correct grant award period as the grant spanned both fiscal years. This oversight was due to human error. Corrective Action A. Immediate Corrective Action Taken 1.Management reviewed the transaction in question and verified the correct period of performance. 2.The expenditure was reclassified to the appropriate fiscal year. 3.A review of expenditures recorded near the fiscal year-end for all federal awards was conducted to identify any additional cutoff errors. 4.Supporting documentation for corrections was retained. Completion Date: Completed prior to issuance of audited financial statements. B. Long-Term Corrective Actions The organization will implement enhanced year-end closing procedures that will include review of all invoices for the period of service to ensure that expenditures recorded near the start or end of a fiscal year are aligned with the proper fiscal year. Prepaid service expenditures will be recorded as accruals. Responsible Party: Executive Director and Contractual Bookkeeper Implementation Date: Beginning current fiscal year-end and ongoing.

View Audit 392932

Finding 1181662 (2023-004)

Material Weakness 2023

Maryland Network Against Domestic Violence, INC

MD

Questioned Costs Subrecipient Monitoring Material Weakness

Summary of Finding The Organization did not submit reports timely for three out of three reports tested (100%). This is considered to be a material weakness to the reporting compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-004. Statistical ...

Summary of Finding The Organization did not submit reports timely for three out of three reports tested (100%). This is considered to be a material weakness to the reporting compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-004. Statistical sampling was not used in making sample selections. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-004. Due to staff turnover and the limited capacity of agency staff and contractors, MNADV has been late in grant reporting. Corrective Action Long-Term Corrective Action: To address the pattern of late reports, the organization has elected to move financial reporting to a quarterly basis whenever the grant award allows as opposed to monthly to reduce the number of required reports. Also, the executive director has elected to train additional staff on programmatic grant reporting in an effort to increase capacity. These two measures will effectively address the problem of late reporting. Responsible Parties: Executive Director, Deputy Director and Contractual Bookkeeper Completion Date: These measures were put into place starting with FY25 which began on October 1, 2024.

View Audit 392932

Finding 1180758 (2023-001)

Material Weakness 2023

FREEDOM HOUSE DETROIT

MI

Reporting Questioned Costs

Criteria: The audit must be completed and the data collection form must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition: The audit report and data collection form were not submitted within nine ...

Criteria: The audit must be completed and the data collection form must be submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition: The audit report and data collection form were not submitted within nine months of the year end; specifically, no later than September 30, 2024. Corrective Action Plan: Freedom House Detroit (FHD) acknowledges that per the grant terms of CDFA# 21.027 - COVID-19 Coronavirus State and Local Fiscal Recovery Funds and 93.604 - Assistance for Torture Victims the 2023 audit was to be completed by 09/30/2024. The circumstances surrounding the late submission were based on issues outside of FHD's full control. FHD had issues with its last audit firm, which it is currently still trying to resolve. This resulted in contracting with a new firm, Glen Olivache CPA PC, to assist with the 2023 audit in 2025. These issues were documented in writing to the former firm. FHD could not finish the 2023 audit because the 2022 audit took so long with the former auditing firm. In turn, Glen Olivache CPA PC had to also do its due diligence as a new auditor and review all aspects of the organization's operations which would normally have been taken care of by a long standing auditor but under a new auditor took longer. The switch to a new auditor, while the correct choice, caused the 2023 audit to be significantly delayed. No matter the procedures FHD would have put in place to ensure timely submission, these extenuating circumstances would not have been avoided. FHD has now contracted with Glen Olivache CPA PC and will immediately begin its 2024 audit. This audit will also be out of date but should take substantially less time as Glen Olivache CPA PC will be a continuing auditor. The FHD team is currently preparing for the next audit and plans to be back on track by the end of 2026 with all audit timelines and submissions. Name(s) of Contact Person(s) Responsible for Corrective Action Plan: Name: Elizabeth Orozco Vasquez, CEO Name: Erin Decker, Director of Finance

View Audit 392439

Finding 1180711 (2023-004)

Material Weakness 2023

Souris River Joint Water Resource Board

ND

Questioned Costs

A. Prior Year Findings -The prior year finding is a repeat finding in the current year B. Comments on Findings and Recommendations - We concur with the findings. C. Actions Taken or Planned - Board will track all necessary filings and deadlines to ensure timely filings occur.

View Audit 392355

Finding 1179879 (2023-004)

Material Weakness 2023

North Homes, Inc.

MN

Questioned Costs Cash Management Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed a...

Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed and approved prior to submission. Corrective Action Plan: The Organization has implemented a process to ensure that formal documentation of review and approval is obtained and retained (i.e. hard copies or email). Responsible Individual: Ashli Glorvigen, CFO Anticipated Completion Date: 12/31/2026

View Audit 392245

Finding 1179665 (2023-003)

Material Weakness 2023

Lake County

IN

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303 § 200.308 § 200.403

FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the f...

FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding with reservations on a portion of the Finding. Description of Corrective Action Plan: \ This program is completed and the period of performance is over therefore there is not a need to formally adopt any Corrective Action Plan. The Subrecipient Contractor that administered the program has agreed that this finding was due to their internal error in submitting administration invoices too late to be properly processed and approved by the County. They will be reimbursing the ERA1 fund for the error in the amount of $154,812.56 that will be sent back to the US Treasury. Reservation: The US Treasury required the local grant recipient to prosecute ERA1 fraud activities. There were two fraud cases that were prosecuted by our local attorney. His fees were then deducted from the ERA1 fund as administration costs. The grant recipient should not be penalized for doing as directed to prosecute fraud cases without being able to pay for the services rendered. We do not control the timelines of the local courts nor the responses/actions of the defendants delaying the actions beyond the Period of Performance. Anticipated Completion Date: None, no corrective action plan is necessary.

View Audit 392081

Finding 1179663 (2023-003)

Material Weakness 2023

Legacy Senior Services

MN

Questioned Costs Reporting Significant Deficiency § 200.303

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (H...

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP Rural Distribution) Assistance Listing Number: 93.498 Finding Summary: The Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 5 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt Corrective Action Plan: Before future reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: January 2025

View Audit 392080

Finding 1179349 (2023-004)

Material Weakness 2023

East Alabama Regional Planning and Development Commission

FL

Subrecipient Monitoring Questioned Costs § 200.332 § 200.501

We will implement the required procedures surrounding the subrecipient monitoring process and follow them consistently.

View Audit 391711

Finding 1179344 (2023-003)

Material Weakness 2023

East Alabama Regional Planning and Development Commission

FL

Questioned Costs Allowable Costs / Cost Principles Reporting

We plan to start the next fiscal year's audit right after issuance of September 30, 2023 financial statements to catch up on the filing of the reporting package.

View Audit 391711

Finding 1177961 (2023-001)

Material Weakness 2023

Center for Pan Asian Community Services, Inc.

GA

Questioned Costs Eligibility

We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: June 16, 2025

View Audit 391400

Finding 1176890 (2023-002)

Material Weakness 2023

State of Kosrae

FM

Questioned Costs Eligibility

We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This informa...

We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This information will be kept in each patient’s file and will be updated on a regular basis to ensure the continued compliance of the WCHC to the discount policy. March 31, 2026 Ms. Irene Laabrug Chief, Division of Finance & Treasury (691)350-2142ilaabrug123@gmail.com

View Audit 390739

Corrective Action Plans

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