Corrective Action Plans

Finding 208 (2022-003)

Material Weakness 2022

County of Mifflin

PA

Questioned Costs Reporting Internal Control / Segregation of Duties

Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Hum...

Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to insure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2023

View Audit 384

Finding 193 (2022-004)

Material Weakness 2022

Nulato Tribal Council

AK

Questioned Costs Material Weakness Reporting § 200.512

Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023....

Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023. In April the unrecorded liabilities identified in Finding 2022-001 were discovered, which took some time with the parties involved to agree the actual balances owed. With the tying out of internal transactions monthly this should not be an issue in the future. Proposed Completion Date: June 30, 2024

View Audit 297

Finding 192 (2022-003)

Material Weakness 2022

Nulato Tribal Council

AK

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.305

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced f...

Finding 2022-003 Lack of Internal Controls Over Cash Management Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with the recommendation. Funds to transferred to NorthRim Bank on January 17, 2023 resulting in compliance with 2 CFR Section 200.305 advanced federal funding. The service being used to insure all deposits is called IntraFI Cash services. This is a sweep account that will automatically move all deposits to other financial institutions to assure that they are under the 250,000 limit. Funds are wholly available at any time. Proposed Completion Date: Already implemented.

View Audit 297

Finding 164 (2022-102)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Cash Management Eligibility § 200.303

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.

View Audit 240 Questioned Costs: $1

Finding 161 (2022-101)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Matching / Level of Effort / Earmarking § 200.303

To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The Co...

To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. The County will monitor the out-of-school services spending throughout the fiscal year and award period.

View Audit 240 Questioned Costs: $1

Finding 125 (2022-001)

None 2022

Maimonides Medical Center

NY

Questioned Costs Reporting

2022-001 – Reporting of Provider Relief Fund (“PRF”) Lost Revenues Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration Award Name: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistanc...

2022-001 – Reporting of Provider Relief Fund (“PRF”) Lost Revenues Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration Award Name: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – Period 4 Award Year: January 1, 2020 – December 31, 2022 Management of Maimonides Midwood Community Hospital have reached out to HRSA on September 5, 2023 to determine if any corrective action related to the reporting error is necessary. HRSA responded and advised that the reporting portal is closed and changes can no longer be made to the report. HRSA also advised to maintain all records that pertain to expenditures and other data related to the PRF payment for three (3) years. Management will review any future PRF submissions to ensure that HRSA instructions are appropriately followed. Responsible Individual: Robert Palermo, Executive Vice President Chief Financial Officer

View Audit 206

Finding 74 (2022-001)

None 2022

Health Services Management, INC

TN

Questioned Costs Reporting

FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Sc...

FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Scott Fisher PERSON RESPONSIBLE FOR IMPLEMENTING THE CORRECTIVE ACTION: Scott Fisher ANTICIPATED COMPLETION DATE OF CORRECTIVE ACTION: December 31, 2023 PLANNED CORRECTIVE ACTION: Management will review all the EINs associated with each facility to ensure the PRF funding received has been accounted for and properly reported in the Provider Relief Fund Reporting Portal.

View Audit 82 Questioned Costs: $1

Finding 73 (2022-002)

Material Weakness 2022

Chuan Teng

CA

Questioned Costs Material Weakness Reporting § 200.512

Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 ...

Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 audit will be submitted to the FAC within the March 31, 2024 deadline (nine months after the end of our fiscal year). Anticipated completion date: March 31, 2024. Responsible person: Leo Levenson, Consulting CFO.

View Audit 76

Finding 66 (2022-001)

Material Weakness 2022

County of Madera

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient....

The Community and Economic Development Planning Division has implemented the following procedures for the fiscal year ending June 30, 2023. For non-compliant loans that do not provide responses to annual residency and request for home insurance three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. For Economic Development loans an annual audit will be conducted June to ensure that the requirements of the grant are met. If audit finds any non-compliance issues are found three letters will be sent by mail to grant recipient. If a response is not received a certified letter will be sent with the request for information followed by a phone call to the number on file. The final step is to send a certified letter stating the loan is out of compliance and will become due and payable in full. We will update our loan receivables listing to include a compliance check box which indicate that the loan is complying and actually a receivable at the end of the year.

View Audit 61 Questioned Costs: $1

Finding 1223565 (2021-001)

Material Weakness 2021

TOWN OF LEXINGTON

MA

Internal Control / Segregation of Duties Questioned Costs § 200.512

Audit Finding Reference: 2021-001 Timely Filing of Single Audit Report Planned Corrective Action: The Town of Lexington, including the municipal and school finance departments, will jointly address the timely filing of Single Audit reports. The preparation of the SEFA has been assumed by the Town Ac...

Audit Finding Reference: 2021-001 Timely Filing of Single Audit Report Planned Corrective Action: The Town of Lexington, including the municipal and school finance departments, will jointly address the timely filing of Single Audit reports. The preparation of the SEFA has been assumed by the Town Accountant beginning with fiscal year 2024 (previously prepared by the external audit team). Going forward, the Town has developed the following schedule to maintain timely filing within 9 months of fiscal year end: July-August Town staff perform fiscal year-end reconciliations and General Ledger close. Assistant Town Manager for Finance to schedule kick-off meeting with CBiz Audit team; establish audit calendar/timeline. Responsible Personnel Municipal and School finance teams; CBiz Single Audit team September-October School Lunch data to be provided by School Finance to Town Accountant by September 30th. SEFA to be completed by the Town Accountant and sent to CBiz by October 31st. Responsible Personnel Town Accountant, School Finance Director October-February Receipt of detailed audit request list from CBiz Audit team. Sample testing to be divided between Municipal and School transactions (split by Town Accountant if initially combined). Town Accountant and School Finance Director to monitor and ensure their respective requests are processed within 10 business days. Same with follow-up questions/requests. Suralink platform to be utilized for item tracking and completion. Audit team communications should include both School and Municipal staff to ensure coordination Responsible Personnel Town Accoutant; School Finance Director March Review Audit report and findings. Completion and submission of Single Audit, in conjunction with primary audit, by March 31st. Responsible Personnel Assistant Town Manager for Finance; Assistant Superintendent for Finance and Operations Planned Implementation Date of Corrective Action: The Town of Lexington, including municipal and school finance departments, intends to complete all outstanding Single Audits from fiscal years 2022-2025 within the next 12 months, ending June 30, 2027. Future Single Audits will adhere to the timeline above. Person Responsible for Corrective Action: Carolyn Kosnoff, Assistant Town Manager for Finance

View Audit 406972

Finding 1219591 (2021-007)

Material Weakness 2021

University of the Virgin Islands

VI

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

The University will implement internal controls and procedures to ensure that the prevailing wage rate clause is included in all federally funded construction contracts in compliance with applicable regulations. The Principal Investigator (PI) will collaborate with Purchasing & Contracts (P&C) and t...

The University will implement internal controls and procedures to ensure that the prevailing wage rate clause is included in all federally funded construction contracts in compliance with applicable regulations. The Principal Investigator (PI) will collaborate with Purchasing & Contracts (P&C) and the Office of Sponsored Programs (OSP) on construction-related projects and will be responsible for flagging the prevailing wage requirement during the planning phase. The Purchasing Department will ensure the clause is included in all solicitations and bid packages for applicable projects. The Project Manager (PM) will be responsible to review all submitted bids to verify that minimum standards, including federal prevailing wage requirements, are met. Finally, the prevailing wage clause will be explicitly incorporated into the final contract and associated Purchase Orders (POs) to ensure full compliance with federal grant conditions and U.S. Department of Labor regulations. This process ensures consistency, accountability, and compliance across all units involved in construction.

View Audit 405175

Finding 1219590 (2021-006)

Material Weakness 2021

University of the Virgin Islands

VI

Reporting Questioned Costs

Management will reinforce internal controls and procedures to ensure that all required Performance Progress Reports (PPRs) for the Small Business Development Centers program are completed, reviewed, and submitted timely. Responsibilities will be clearly assigned to program and fiscal personnel, repo...

Management will reinforce internal controls and procedures to ensure that all required Performance Progress Reports (PPRs) for the Small Business Development Centers program are completed, reviewed, and submitted timely. Responsibilities will be clearly assigned to program and fiscal personnel, reporting deadlines will be tracked using a formal reporting calendar, and reports will be subject to timely supervisory review prior to submission. Supporting documentation will be retained in accordance with federal record retention requirements to evidence compliance.

View Audit 405175

Finding 1219588 (2021-004)

Material Weakness 2021

University of the Virgin Islands

VI

Questioned Costs Reporting Internal Control / Segregation of Duties

The Controller will work with the Grant Accountants to implement and document internal controls and procedures to ensure that all Federal financial reports are completed, reviewed, and submitted in a timely manner. These procedures will include requirements for maintaining supporting documentation a...

The Controller will work with the Grant Accountants to implement and document internal controls and procedures to ensure that all Federal financial reports are completed, reviewed, and submitted in a timely manner. These procedures will include requirements for maintaining supporting documentation as evidence that the control process was followed. Additionally, the accounting team will ensure that all Grant Accountants have access to the necessary reporting modules to prevent any reports from being overlooked.

View Audit 405175

Finding 1217899 (2021-001)

Material Weakness 2021

Tanner Medical Center, Inc.

GA

Questioned Costs Reporting

Tanner Medical Center, Inc. (Medical Center) respectfully submits the following corrective action plan for the year ended June 30, 2021. The findings from the June 30, 2021 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned ...

Tanner Medical Center, Inc. (Medical Center) respectfully submits the following corrective action plan for the year ended June 30, 2021. The findings from the June 30, 2021 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDITS FINDINGS Other Matter - Noncompliance (2021-001) Recommendation: We recommend the Medical Center continue to review submissions to ensure consistency and accuracy of calculations, and reconciliations to supporting source documentation. Any corrections should be made at the time of discovery. Planned Corrective Action: The Medical Center agrees with finding and will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. Carol Crews Chief Financial Officer

View Audit 403999

Finding 1217719 (2021-004)

Material Weakness 2021

Escambia County Healthcare Authority

AL

Questioned Costs Reporting

FINDINGS - FEDERAL AWARD PROGRAM AUDIT Compliance Finding 2021-004 COVID-19 Provider Relief Fund (PRF) - Period 1 Recommendation: We recommend the Authority design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines. A...

FINDINGS - FEDERAL AWARD PROGRAM AUDIT Compliance Finding 2021-004 COVID-19 Provider Relief Fund (PRF) - Period 1 Recommendation: We recommend the Authority design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines. Action Taken: Management will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. The Authority agrees with this finding, however, does note there are additional coronavirus related expenses that were not included with the Period 1 submission and excess loss revenues included in the Period 1 submission that management believes would offset the issue identified above. Wes Nall, CFO

View Audit 403848

Finding 1217594 (2021-001)

Material Weakness 2021

The Arizona Partnership for Immunization

AZ

Questioned Costs Cash Management Eligibility § 200.303

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evid...

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evidence eligibility determinations, particularly during periods of increased service volume, to support accurate and allowable program charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action taken in response to finding: Effective 4/2022, management has taken deliberate steps to strengthen documentation and standardize eligibility determination and insurance verification processes. These efforts include the development and formalization of written policies and procedures to ensure consistent application, improved documentation standards, and sustained compliance with HRSA award requirements. Name(s) of the contact person(s) responsible for corrective action: James Washington, Executive Director and Bernie Soderberg, Program Manager. Planned completion date for corrective action plan: December 2023

View Audit 403738

Finding 1217317 (2021-007)

Material Weakness 2021

Country Doctor Community Health Centers

WA

Allowable Costs / Cost Principles Cash Management Questioned Costs § 200.403

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard ...

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard requirements are now in place to maintain complete supporting documentation for each draw, including linkage to underlying expenses. Review and Approval Controls: Formal review procedures have been established, requiring documented evidence of supervisory review and approval prior to submission of draw requests. Anticipated completion date: Completed in 2022 Contact person responsible for corrective action: Angela Treptow, Interim Finance Director

View Audit 403489

Finding 1214952 (2021-004)

Material Weakness 2021

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles Questioned Costs Special Tests & Provisions

Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Y...

Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 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 including 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 and Public and Indian Housing 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 and Public and Indian Housing Programs to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2022.

View Audit 401726

Finding 1213600 (2021-002)

Material Weakness 2021

Richmond Housing Authority

CA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Finding Reference Number: SA2021-002: Lack of Supporting Documentation for Expenditures Assistance Listing Number: 14.850 Assistance Listing Title: Public and Indian Housing Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive Director Cor...

Finding Reference Number: SA2021-002: Lack of Supporting Documentation for Expenditures Assistance Listing Number: 14.850 Assistance Listing Title: Public and Indian Housing Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive Director Corrective Action Plan: Staff have implemented procedures requiring that all invoices, contracts, purchase orders, and supporting records be scanned and attached in MUNIS at the time of processing. A new review workflow ensures supervisory approval before expenditures are charged to federal funds. The Authority is conducting retroactive file recovery where possible and implementing staff training on documentation requirements under 2 CFR Part 200. These improvements will ensure expenditures are fully supported, allowable, and readily accessible for audit. Completion Date: May 1, 2023

View Audit 400515

Finding 1208253 (2021-001)

Material Weakness 2021

CORPORACION DEL FONDO DEL SEGURO DEL ESTADO

PR

Reporting Internal Control / Segregation of Duties Questioned Costs

As part of the preventive measures to file the Single Audit in a timely manner, an employee was selected to specifically dedicate time and effort related to auditing processes. Coordination of weekly meetings and phone calls with the external audit firm and the Programs has rendered immediate result...

As part of the preventive measures to file the Single Audit in a timely manner, an employee was selected to specifically dedicate time and effort related to auditing processes. Coordination of weekly meetings and phone calls with the external audit firm and the Programs has rendered immediate results to follow through with an established work plan. Therefore, time has been properly managed to collect the necessary information.

View Audit 399238

Finding 1205746 (2021-002)

Material Weakness 2021

Rocky Mountain Tribal Leaders Council

MT

Questioned Costs Reporting

RMTLC hired a new CPA to help with the process of completing the audit on time in the future. Unfortunately, we are still in catch-up mode and have a learning curve for getting the audits completed on time. The COVID-19 situation also delayed the process for our finance team. This finding will conti...

RMTLC hired a new CPA to help with the process of completing the audit on time in the future. Unfortunately, we are still in catch-up mode and have a learning curve for getting the audits completed on time. The COVID-19 situation also delayed the process for our finance team. This finding will continue for the 2022 audit and several following years.

View Audit 397476

Finding 1181992 (2021-009)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs 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 i...

Department of Housing and Urban Development and Department of Veterans Affairs 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

View Audit 393351

Finding 1181990 (2021-008)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Questioned Costs Reporting Significant Deficiency § 200.303

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and subm...

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and submitted within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented formal reporting controls to ensure all required reports are prepared accurately, reviewed appropriately, and submitted within the required timelines. These controls include a structured reporting calendar with submission deadlines, assignment of responsibility for report preparation and review, and a standardized review and approval process prior to submission. The Organization has also developed documentation procedures to retain evidence of supervisory review, validation of key data points, and confirmation of timely submission. These enhancements are intended to reduce risk of late submissions and improve the accuracy and consistency of program reporting. 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

View Audit 393351

Finding 1177797 (2021-013)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Questioned Costs Cash Management Material Weakness

2021-013 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...

2021-013 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.

View Audit 391158

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calcu...

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calculation was incorporated into the Period 4 PRF submission. To prevent recurrence, the Organization has strengthened its internal review protocols for reporting, including mandatory reconciliation of all revenue inputs to audited financial statements and secondary review by the Regional Controller prior to submission. These enhanced controls ensure that future lost revenue calculations are accurate, supportable, and compliant with HRSA reporting requirements.

View Audit 390602

Corrective Action Plans

Filters