Corrective Action Plans

Finding 561616 (2023-006)

Significant Deficiency 2023

Ramsey County

MN

Internal Control / Segregation of Duties Student Financial Aid Eligibility § 200.303

Finding Number: 2023-006 Finding Title: Reporting – DHS Social Service Fund (DHS-2556) Program: 93.658 Foster Care – Title IV-E Name of Contact Person Responsible for Corrective Action: Janelle White – Controller for Ramsey County’s Health & Wellness Service Team Enrique Rivera – Fiscal Services ...

Finding Number: 2023-006 Finding Title: Reporting – DHS Social Service Fund (DHS-2556) Program: 93.658 Foster Care – Title IV-E Name of Contact Person Responsible for Corrective Action: Janelle White – Controller for Ramsey County’s Health & Wellness Service Team Enrique Rivera – Fiscal Services Manager for Ramsey County’s Health & Wellness Service Team Corrective Action Planned: Starting in the third quarter of 2024, Ramsey County instituted an additional verification step in the review process to support the determination of accurate cost pool categorization of reimbursable costs for the Random Moment Time Study Reports cost reports. The additional step will be to confirm that on the Summary Tab of the Quarterly Payroll file, the cost codes lines are in sequential order and that the corresponding expense totals match the cost code. The Senior Accountant will do the first review of this step, and the Fiscal Manager will complete the second review. The error on the 2nd quarter 2023 report was remedied and resubmitted in the 2nd quarter of 2024. Anticipated Completion Date: July of 2024 when the 2nd quarter DHS-2556 and DHS 2550 are due to be complete and finalized.

View Audit 357223

Finding 561612 (2023-005)

Significant Deficiency 2023

Ramsey County

MN

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding Number: 2023-005 Finding Title: Reporting – PR29 – CDBG Cash on Hand Quarterly and Federal Funding and Accountability and Transparency Act Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Co...

Finding Number: 2023-005 Finding Title: Reporting – PR29 – CDBG Cash on Hand Quarterly and Federal Funding and Accountability and Transparency Act Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Max Holdhusen, Deputy Director of Community and Economic Development Corrective Action Planned: 1) Ramsey County will implement internal procedures to complete PR29 quarterly reports as required by HUD and ensure the correct accounting basis and accounts are being utilized. 2) Ramsey County will implement procedures to complete reports on FSRS required by FFATA. 3) Ramsey County will develop/update our agency’s written grants administration policies and procedures to align with current practices and applicable rules. 4) Ramsey County will conduct regular trainings of policies and procedures for staff involved with CDBG grants administration. Anticipated Completion Date: July 15, 2025

View Audit 357223

Finding 561556 (2023-004)

Significant Deficiency 2023

Listening House of St. Paul, Inc.

MN

Reporting Internal Control / Segregation of Duties

Recommendation – We recommend that management enhance its internal controls, policies and procedures to ensure that all in-kind contributions are properly tracked, valued, and recorded. Auditee's comments and response – Management will implement a process to properly track and record in-kind dona...

Recommendation – We recommend that management enhance its internal controls, policies and procedures to ensure that all in-kind contributions are properly tracked, valued, and recorded. Auditee's comments and response – Management will implement a process to properly track and record in-kind donations. Name(s) and contact person(s) responsible for corrective action: Molly Jalma, Executive Director. Planned completion date for corrective action plan: Ongoing.

View Audit 357162

Finding 561554 (2023-003)

Significant Deficiency 2023

Listening House of St. Paul, Inc.

MN

Reporting Internal Control / Segregation of Duties

Recommendation – We recommend that management enhance its internal controls, policies and procedures to ensure that all filing requirements under federal awards are met. Auditee's comments and response – Management, the Board, and its contracted accounting staff will regularly monitor financial rep...

Recommendation – We recommend that management enhance its internal controls, policies and procedures to ensure that all filing requirements under federal awards are met. Auditee's comments and response – Management, the Board, and its contracted accounting staff will regularly monitor financial reports and activities of Listening House.

View Audit 357162

Finding 561549 (2023-001)

Significant Deficiency 2023

Ute Indian Tribally Designated Housing Entity

UT

Reporting

Management's Response: SF-425 – Housing Authority transition from EPIC to GEMS. Housing Authority will ensure that the single audit reporting package and submitted within the timeline as required by Uniform Guidance. Housing Authority is still familiarizing itself with GEMS portal for all reporting ...

Management's Response: SF-425 – Housing Authority transition from EPIC to GEMS. Housing Authority will ensure that the single audit reporting package and submitted within the timeline as required by Uniform Guidance. Housing Authority is still familiarizing itself with GEMS portal for all reporting requirements. Account issues have also taken time away from completing requirements in GEMS. Estimated Completion Date: Housing Authority is estimating six months from the time of submission to be completed with this requirement. Responsible Party: Tyson J. Thompson, Executive Director

View Audit 357157

Finding 561522 (2023-004)

Material Weakness 2023

Bates County

MO

Reporting Internal Control / Segregation of Duties

I have tried numerous times to get into the Treasury portal to locate the forms to report how much money went to who. I have even had Treasury personnel on the phone talking me through to get the forms and they couldn’t get them. All I can do is keep trying to locate the forms to upload the informa...

I have tried numerous times to get into the Treasury portal to locate the forms to report how much money went to who. I have even had Treasury personnel on the phone talking me through to get the forms and they couldn’t get them. All I can do is keep trying to locate the forms to upload the information. We have all the applications for the funds accounted for and the money accounted for. It’s just uploading the information that has been the problem. We have until 31 December to allocate the funds and the funds have to be used by 2026.

View Audit 357135

Finding 561474 (2023-006)

Material Weakness 2023

Hopkins Public Schools/isd No. 270

MN

Material Weakness Reporting Internal Control / Segregation of Duties

State and Local Recovery Funds – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Coronavirus State and Local Fiscal Recovery Funds program to ensure all reports are accurately reporting information and are reviewed by someone ...

State and Local Recovery Funds – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Coronavirus State and Local Fiscal Recovery Funds program to ensure all reports are accurately reporting information and are reviewed by someone other than the preparer and that review is documented prior to submission of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will establish procedures to ensure reivew of reports prior to submission by someone other than the preparer. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: June 30, 2025

View Audit 357059

Finding 561466 (2023-004)

Material Weakness 2023

Hopkins Public Schools/isd No. 270

MN

Questioned Costs Cash Management Material Weakness

Child Nutrition – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Child Nutrition Cluster program to ensure all reports are accurately reporting information and are reviewed by someone other than the preparer and that review i...

Child Nutrition – Report Testing Recommendation: We recommend that the District reviews its procedures and controls over reporting for the Child Nutrition Cluster program to ensure all reports are accurately reporting information and are reviewed by someone other than the preparer and that review is documented prior to submission of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will review its procedures over its reporting of claims to MDE to ensure claims made to MDE is properly supported by the District's meals count. Name(s) of the contact person(s) responsible for corrective action: Tariro Chapinduka, Director of Business Services Planned completion date for corrective action plan: June 30, 2025

View Audit 357059 Questioned Costs: $1

Finding 561429 (2023-002)

Material Weakness 2023

Community Resource Center, Inc.

CO

Reporting

Community Resource Center, Inc. acknowledges the finding and recommendation. Errors in the SEFA preparation were due to manual data entry and a lack of comprehensive training on Uniform Guidance requirements. Community Resource Center, Inc. is taking immediate steps to address these issues. Communit...

Community Resource Center, Inc. acknowledges the finding and recommendation. Errors in the SEFA preparation were due to manual data entry and a lack of comprehensive training on Uniform Guidance requirements. Community Resource Center, Inc. is taking immediate steps to address these issues. Community Resource Center, Inc. will provide Uniform Guidance training to finance staff by June 2025, ensuring familiarity with SEFA requirements. A new data specialist, to be hired in 2024, will support accurate data collection and reporting. Community Resource Center, Inc. will implement a review process involving both internal staff and an external financial consultant to ensure the SEFA is complete and accurate before submission.

View Audit 357014

Finding 561278 (2023-003)

Significant Deficiency 2023

Housing Authority of the City of Renton

WA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Prior RHA administrative staff were not getting the PHA’s Single Audit completed nor submitted by the deadline. RHA was 3 years behind when the new CEO took over on March 31, 2023. FY2020, FY2021 and FY2022 were not completed and submitted. By the time that these three were caught up, completed...

Prior RHA administrative staff were not getting the PHA’s Single Audit completed nor submitted by the deadline. RHA was 3 years behind when the new CEO took over on March 31, 2023. FY2020, FY2021 and FY2022 were not completed and submitted. By the time that these three were caught up, completed and submitted, that pushed FY2023 Audit to be late. The audit for FY2023 should be completed by the end of April 2025 and then we will be on task to start FY2024 in May and completed by the deadline of September 30, 2025. Then, RHA will stay on task and get these completed within its deadline timeline.

View Audit 356918

Finding 561273 (2023-003)

Material Weakness 2023

Knott County Fiscal Court

KY

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.306 § 200.318 § 200.329

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will ende...

Prepared by: Kevin Jacobs Date Prepared: 7-3-24 Person Responsible for Corrective Action Plan: Kevin Jacobs Jeff Dobson Anticipated Completion Date: 7-3-24 Official's Response: To be clear the documents had to be presented to FEMA to get reimbursement, this was done. The Fiscal Court will endeavor to make sure the FEMA files are updated and complete after FEMA reimbursement.

View Audit 356900 Questioned Costs: $1

Finding 561267 (2023-001)

Significant Deficiency 2023

Housing Authority of Carbon County

UT

HUD Housing Programs Reporting

The Housing Authority will implement a standardized process for documenting rent reasonableness across all tenant files, including those from the Emery County merger, and will explore automated tools to streamline the determination and documentation process. Staff will also receive training to ensur...

The Housing Authority will implement a standardized process for documenting rent reasonableness across all tenant files, including those from the Emery County merger, and will explore automated tools to streamline the determination and documentation process. Staff will also receive training to ensure compliance with the requirements moving forward.

View Audit 356886

Finding 561210 (2023-002)

None 2023

National Indian Youth Council, Inc.

NM

Reporting

NIYC has worked to get caught up with annual single audit submissions. Since developing the Accounting Manager position in 2022, NIYC has completed the single audit for 2021 and 2022. We are currently working with our auditor to start the 2023 audit in a timely manner so that it can be submitted on ...

NIYC has worked to get caught up with annual single audit submissions. Since developing the Accounting Manager position in 2022, NIYC has completed the single audit for 2021 and 2022. We are currently working with our auditor to start the 2023 audit in a timely manner so that it can be submitted on time. NIYC is committed to prioritizing our annual single audits to ensure that moving forward, they will be submitted on time.

View Audit 356835

Finding 561173 (2023-001)

Significant Deficiency 2023

Native Village of Nunapitchuk

AK

Reporting Significant Deficiency § 200.512

Finding 2023-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Eli Wassillie, Tribal Administrator Corrective Action Plan: Management will engage a CPA firm with enough advanced timing to ensure that the single audit is completed and submitted with in the 9-month ti...

Finding 2023-001 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Eli Wassillie, Tribal Administrator Corrective Action Plan: Management will engage a CPA firm with enough advanced timing to ensure that the single audit is completed and submitted with in the 9-month time period. Proposed Completion Date: December 31, 2024

View Audit 356764

Finding 561171 (2023-001)

Significant Deficiency 2023

M. Carter Plaza

OR

Subrecipient Monitoring HUD Housing Programs Reporting § 200.512

Finding no.: 2023-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to significant turnover in the Fiscal Department beginning in 2021. Work was delayed as new staff required training on processes in conjunction with workin...

Finding no.: 2023-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to significant turnover in the Fiscal Department beginning in 2021. Work was delayed as new staff required training on processes in conjunction with working through a large backlog of work in the Department that was necessary to complete in order to prepare the Financial Statements for audit. In addition to adapting its processes in the Fiscal Department to ensure the continuance of proper separation of duties and adherence to policies and procedures during staff transitions, Management is developing procedures to hire, train, and retain Fiscal Staff to help stabilize the department to ensure the work can continue in the event of unexpected staff turnover. Management is aware of the deadline related to the submission of the data collection form and anticipates that these measures will have a positive impact on the timeliness of future submissions. Anticipated completion date: October 2023

View Audit 356761

Finding 561162 (2023-001)

Material Weakness 2023

Sbh Community Service Network, Inc.

NY

Reporting

Corrective Action Plan For the Year Ended December 31, 2023 Finding Reference Number: 2023‐001 Finding Late submission of reporting package and data collection form. Finding Type Noncompliance of Reporting Agency U.S. Department of Health and Human Services ALN 93.696 Certified Community Behavioral ...

Corrective Action Plan For the Year Ended December 31, 2023 Finding Reference Number: 2023‐001 Finding Late submission of reporting package and data collection form. Finding Type Noncompliance of Reporting Agency U.S. Department of Health and Human Services ALN 93.696 Certified Community Behavioral Health Clinic (CCBHC) Expansion Grants Recommendation SBH should enhance internal control procedures to ensure amounts expended for each federal program are being monitored and to ensure the timely preparation of the Schedule of Expenditures of Federal Awards, as required under the Uniform Guidance. Corrective Action Management agrees that the closing process needs to be improved to allow for timely closing of the general ledger and financial reporting in compliance with federal and other regulatory deadlines. The Finance Department will develop and implement a policy outlining the procedures for compiling the SEFA, including responsibilities, timelines, and required documentation. The Grants Manager will be assigned as the SEFA Coordinator to oversee the preparation and ensure timely completion. The Controller will review the SEFA for accuracy and completeness before submission. A checklist will be used to verify that all federal programs are accounted for and that the report complies with Uniform Guidance. Name of Responsible Person Jeff Gass, Chief Financial Officer Anticipated Completion Date June 30, 2025

View Audit 356746

Finding 561098 (2023-005)

Significant Deficiency 2023

Public Health Institute of Metropolitan Chicago

IL

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.430

Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, another instance was identified in which a timesheet was not complete and was missing hours worked. Corrective Action Taken or Planned: Management ...

Condition: We identified an instance in which a timesheet was not signed off by applicable supervisor and there was no evidence of review. In addition, another instance was identified in which a timesheet was not complete and was missing hours worked. Corrective Action Taken or Planned: Management plans to reiterate the applicable policy and ensure timesheets are prepared, reviewed and contain the appropriate approvals. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Karen Reitan, President and Chief Executive Officer Management Response: Management concurs with the finding.

View Audit 356735

Finding 561096 (2023-002)

Significant Deficiency 2023

Public Health Institute of Metropolitan Chicago

IL

Reporting

Condition: PHIMC did not submit its 2023 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse within the earlier of nine months following its fiscal year end, or 30 days after receipt of the auditors' report. Corrective Action Taken or Planned: Management concu...

Condition: PHIMC did not submit its 2023 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse within the earlier of nine months following its fiscal year end, or 30 days after receipt of the auditors' report. Corrective Action Taken or Planned: Management concurs and plans to submit the December 31, 2024 data collection form and single audit reporting package on or before September 30, 2025 in conjunction with the hiring of a professional services firm which provides accounting and finance support. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Karen Reitan, President and Chief Executive Officer Management Response: Management concurs with the finding.

View Audit 356735

Finding 561006 (2023-004)

Material Weakness 2023

Northside Properties, Inc.

FL

HUD Housing Programs Procurement, Suspension & Debarment Material Weakness

Federal Award Findings: Finding 2023-004 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Housing Assistance Payments Program Material Weakness in Inte...

Federal Award Findings: Finding 2023-004 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission 14.155 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Housing Assistance Payments Program Material Weakness in Internal Control – Material Noncompliance Condition: The Organization’s annual financial statement data was not submitted within the timeframes specified by HUD. The financial statement data was due by March 31, 2024, but the financials were not issued until May 20, 2025. The Organization was also required to submit the OMB Data Collection Form to the Federal Audit Clearinghouse (“FAC”) by September 30, 2024, but was not filed timely as the audit was completed on May 20, 2025. Auditor’s Recommendation: We recommend that the Organization make every effort to submit its annual financial statement data within the timeframe specified by HUD. Action Taken: The Organization has maintained contact with HUD and prioritized submitting the annual financial statement data after they were informed it was late. Effective Date: May 20, 2025 Contact Information: Kristy Hust, Director of Operations Northside Mental Health Center, Inc. Management Agent 12512 Bruce B Downs Blvd Tampa, FL 33612 (813) 977-8700

View Audit 356648

Finding 561001 (2023-001)

Material Weakness 2023

Cedarville Rancheria

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Federal Awards Finding 2023-001: Tribal Council Leadership & Oversight Finding/Condition Those charged with oversight of the Rancheria’s financial accounting and reporting system have not adequately implemented a system to ensure that it is properly utilized for Rancheria operations. The weaknesse...

Federal Awards Finding 2023-001: Tribal Council Leadership & Oversight Finding/Condition Those charged with oversight of the Rancheria’s financial accounting and reporting system have not adequately implemented a system to ensure that it is properly utilized for Rancheria operations. The weaknesses in the system are as follows: 1. A system has not been completely developed and implemented to allow for centralized grant management, ongoing monitoring of program budgets or other tribal activities. 2. Accurate financial reporting is not being completed for the Tribal Council at regular Council meetings. Planned Corrective Action Governance and management concur with this finding, and are implementing corrective measures. Anticipated Completion Date December 31, 2024

View Audit 356634

Finding 560993 (2023-008)

Significant Deficiency 2023

Heading Home

NM

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing policies and procedures found in Section II Policy #201 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the ...

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing policies and procedures found in Section II Policy #201 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the policies and procedures to ensure all invoices and funds requests are properly reviewed and approved prior to processing. All invoices and requests for funds for fiscal year 2024 will be reviewed to ensure the payment request is reasonable and necessary. The invoice or funds request will be signed and dated by the preparer, as well as by the reviewer as evidence of approval for processing the payment. All invoices and funds requests will be maintained in the cloud server in a manner that allows them to be easily retrieved when needed. The disbursements in question were reviewed and found to be to vendors regularly used by Heading Home and Heading Home firmly believes that documentation of approval existed at one point in time. However, with the complete turnover in executive personnel during 2023, and the fact that the prior administration utilized an online system for document storage that the current administration has very little access to, we were unable to locate the approvals for these payments. Management anticipates the above corrective action plan to be fully implemented by June 30, 2024. Personnel responsible for ensuring implementation include Connie Chavez, Chief Executive Officer, Debbie Brickman, Chief Financial Officer, and Armando Sanchez, contract accountants team lead.

View Audit 356632

Finding 560983 (2023-006)

None 2023

Heading Home

NM

Reporting § 200.512

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals...

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their roles. These positions include a new Chief Executive Officer, Director of Operations, Chief Financial Officer, and Director of Human Services. To address challenges in accounting and finance Heading Home has contracted with a local CPA firm specializing in nonprofit accounting and financial reporting to assist the CFO with daily accounting tasks, the monthly close, financial reporting to management and the board of directors, and to facilitate and ensure audits are completed timely each year. The new management group is committed to maintaining a skilled and competent team in key financial roles. Heading Home’s accounting team is now in the process of preparing for the 2024 audit and anticipates the audit to be completed by December 31, 2025. While this will once again result in a late filing, the new management team has made significant strides in a short amount of time and anticipates that the 2025 and all future audits will be submitted on or before the March 31st due date. Management anticipates the above corrective action plan to be fully implemented by March 30, 2026. Personnel responsible for ensuring implementation include Connie Chavez, Executive Director, Debbie Brickman, Chief Financial Officer, and Armando Sanchez, contract accountant team lead.

View Audit 356632

Finding 560856 (2023-002)

Significant Deficiency 2023

Tnkids Nutrition

TN

Reporting

he Organization agrees with the auditor’s finding and will take actions to ensure that future documentation and reporting meets the standards required.

View Audit 356610

Finding 560844 (2023-005)

Significant Deficiency 2023

Beaufort Jasper Hampton Comprehensive Services, Inc.

SC

Cash Management Reporting Matching / Level of Effort / Earmarking

We concur with the auditor's findings. We submitted the annual financial report during the period expense reimbursement was received instead of submitting it for the budget periods that ended. We are developing and implementing a grant reporting calendar listing federal financial report (FFR) due da...

We concur with the auditor's findings. We submitted the annual financial report during the period expense reimbursement was received instead of submitting it for the budget periods that ended. We are developing and implementing a grant reporting calendar listing federal financial report (FFR) due dates for all federal grants. We will use the automated alerts from the grants management system to track and remind staff of upcoming reporting deadlines. Lastly, we will maintain audit-ready documentation of each FFR submission.

View Audit 356598

Finding 560797 (2023-005)

Material Weakness 2023

International Association of Forensic Nurses, Inc.

MD

Material Weakness Reporting

Action Taken: • We are producing a timetable and posting it to calendars of the filing dates of all key reports to the relevant authorities and are circulating it widely to all executives including the Board and Finance Committee. • This recommendation is also supported by the work undertaken on inv...

Action Taken: • We are producing a timetable and posting it to calendars of the filing dates of all key reports to the relevant authorities and are circulating it widely to all executives including the Board and Finance Committee. • This recommendation is also supported by the work undertaken on invoice approval, monthly review of financials and updates on the policy on Grants and Federal Awards. • We are also in the process of recruiting a new full-time Finance Director.

View Audit 356575

Corrective Action Plans

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