Corrective Action Plans

Finding 501686 (2023-002)

Material Weakness 2023

Sergeant Bluff-Luton Community School District

IA

Internal Control / Segregation of Duties Reporting

We are reviewing all accounting procedures to determine changes to be implemented. We have implemented changes with our cash receipts, journal entries, wire transfers and bank reconciliations.

View Audit 323734

Finding 501666 (2023-001)

None 2023

Nebraska Health Information Initiative, Inc.

NE

Reporting

2023-001: Finding: Under the Uniform Guidance, Section 200.512, Report Submission, the audit must be completed, and the data collection form and single audit reporting package must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier or 30 calendar days after receipt of the aud...

2023-001: Finding: Under the Uniform Guidance, Section 200.512, Report Submission, the audit must be completed, and the data collection form and single audit reporting package must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier or 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. This deadline would have been September 30, 2024, for the Organization’s reporting for the year ended December 31, 2023. Corrective Actions Taken or Planned: Management submitted the Organization’s December 31, 2023, Single Audit package to the FAC on October 2, 2024.

View Audit 323715

Finding 501664 (2023-004)

Significant Deficiency 2023

Lutheran Child and Family Services of Illinois

IL

Reporting § 200.512

Corrective Actions Planned or Taken With the staffing turnover in key personnel at both LCFS and RSM, the audit was delayed. We have now hired qualified staff and plans to have timely audits in the future. Responsible individual: Mr. Dhiren Shah, CFO (Phone number – 630.248.1181)

View Audit 323714

Finding 501662 (2023-002)

Material Weakness 2023

Lutheran Child and Family Services of Illinois

IL

Questioned Costs Special Tests & Provisions Reporting § 200.303

Corrective Actions Planned or Taken We have instituted a new process to perform rent reasonableness review of all rental units as required and records retained. Completed June 30, 2024. Responsible individual: Valerie Tawrel (Phone number – 331.280.2245)

View Audit 323714 Questioned Costs: $1

Finding 501661 (2023-002)

Significant Deficiency 2023

City of Socorro, Texas

TX

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Management’s view: Management agrees with auditor recommendation. Proposed corrective action: The finance department will reconcile federal grants on a monthly basis. The finance department will generate monthly ARPA expenditure reports from the general ledger that will be reconciled with ARPA recon...

Management’s view: Management agrees with auditor recommendation. Proposed corrective action: The finance department will reconcile federal grants on a monthly basis. The finance department will generate monthly ARPA expenditure reports from the general ledger that will be reconciled with ARPA reconciliation prepared internally by the grants department. Duplicate expenses reported in Annual SLFR Compliance Report will be corrected in next required Annual Report (March 2025). Anticipated correction date: March 2025 Responsible official: Alejandra Valadez, Grants Coordinator

View Audit 323710

Finding 501660 (2023-001)

None 2023

Westward Development, Inc. 084-Eh099

MO

Reporting § 200.512

Management concurs with the auditor's finding and will implement the recommended corrective action plan. Person Responsible: Property Manager and Management Agent. Date of Implementation: October 2023

View Audit 323708

Finding 501648 (2023-003)

None 2023

Town of North Haven, Connecticut

CT

Reporting

The Town will implement procedures to ensure reports are based upon the Town’s general ledger and properly reconciled and in compliance with U.S. Treasury guidelines. The implementation process for the finding noted above will be monitored by the Town’s Director of Administration/Procurement Richar...

The Town will implement procedures to ensure reports are based upon the Town’s general ledger and properly reconciled and in compliance with U.S. Treasury guidelines. The implementation process for the finding noted above will be monitored by the Town’s Director of Administration/Procurement Richard Monico.

View Audit 323682

Finding 501593 (2023-002)

Significant Deficiency 2023

New Reach, Inc.

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding No. 2023-002: Compliance Reporting Description of Finding: The audit and reporting package were not submitted by the due date March 31, 2024. The Organization submitted periodic reports that did not reconcile to the accounting records and were not submitted by the due date. Statement of Conc...

Finding No. 2023-002: Compliance Reporting Description of Finding: The audit and reporting package were not submitted by the due date March 31, 2024. The Organization submitted periodic reports that did not reconcile to the accounting records and were not submitted by the due date. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Action: In August 2024 the Organization engaged the services of an outside consultant who is a practicing CPA with extensive experience auditing not-for profit organizations. The consultant is in the process of reviewing internal controls, policies and related procedures to implement best practices that ensure the books and records are closed timely and accurately. Name of Contact Person: Kellyann Day Chief Executive Officer, (203) 492-4866, kday@newreach.org Projected Completion Date: The project is anticipated to be completed during 2024.

View Audit 323671

Finding 501576 (2023-001)

Material Weakness 2023

New Reach, Inc.

CT

Internal Control / Segregation of Duties Material Weakness Reporting

Finding No. 2023-001: Financial Reporting Description of Finding: In fiscal year 2023, the Organization's accounting processes and internal controls over financial reporting were not functioning timely to support generating complete and accurate financial infonnation. The books and records were not ...

Finding No. 2023-001: Financial Reporting Description of Finding: In fiscal year 2023, the Organization's accounting processes and internal controls over financial reporting were not functioning timely to support generating complete and accurate financial infonnation. The books and records were not closed and finalized timely. Numerous adjustments to the trial balances were made, necessitating revisions to account reconciliations, and grant schedules. Statement of Concurrence or Nonconcurrence: The organization agrees with this finding. Corrective Action: In August 2024 the Organization engaged the services of an outside consultant who is a practicing CPA with extensive experience auditing not-for profit organizations. The consultant is in the process of reviewing internal controls, policies and related procedures to implement best practices that ensure the books and records are closed timely and accurately. Name of Contact Person: Kellyann Day Chief Executive Officer, (203) 492-4866, kday@newreach.org Projected Completion Date: The project is anticipated to be completed during 2024.

View Audit 323671

Finding 501559 (2023-002)

Significant Deficiency 2023

Mexico Water District

ME

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303

Mexico Water District does not agree with this finding. In response to the three projects on which these findings are based, the loan amounts, contractor bids, and the interim financing bank were voted on by the Mexico Water District Board of Trustees. All Pay Request Applications and invoices from ...

Mexico Water District does not agree with this finding. In response to the three projects on which these findings are based, the loan amounts, contractor bids, and the interim financing bank were voted on by the Mexico Water District Board of Trustees. All Pay Request Applications and invoices from the district and any contractors are gone over by the engineer at Dirigo Engineering and U.S.D.A., then brought to a monthly pay requisition meeting for discussion and signed off on by the engineer, U.S.D.A., and the Mexico Water District Superintendent for payment approval. Each Pay Requisition is emailed to the Mexico Water District Administrator and forwarded to the interim financing bank. Only the exact amount for this requisition is forwarded into the project account for disbursement of the exact amounts stated in the pre-approved Pay Requisition. Therefore, we feel that the process in place is sufficient. Also, it would be impractical to implement any further procedures due to limited staffing.

View Audit 323608

Finding 501557 (2023-003)

Significant Deficiency 2023

Adams County, Wisconsin

WI

Reporting Internal Control / Segregation of Duties Significant Deficiency

SLFRF Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: CLA recommends the County develop and implement a process to require review and approval of all required reports prior to the submission of the report to the federal government to help ...

SLFRF Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: CLA recommends the County develop and implement a process to require review and approval of all required reports prior to the submission of the report to the federal government to help ensure that the data reported are accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has reviewed this finding and will implement a more formal process for reviewing and approving of annual filings related to State and Local Fiscal Recovery Funds. Name(s) of the contact person(s) responsible for corrective action: Kyle Patterson Planned completion date for corrective action plan: 12/31/2024

View Audit 323607

Finding 501548 (2023-003)

Material Weakness 2023

City of Avon Park

FL

Reporting

Airport Improvement Program – Assistance Listing No. 20.106 Recommendation: We recommend the City designate a responsible and qualified grant manager, establish internal controls for reporting, and file required reports in a timely and accurate manner. Explanation of disagreement with audit findin...

Airport Improvement Program – Assistance Listing No. 20.106 Recommendation: We recommend the City designate a responsible and qualified grant manager, establish internal controls for reporting, and file required reports in a timely and accurate manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City is in the process of establishing interal controls for reporting and will review file all future required reports in a timely and accurate manner. All reports have been prepared, reviewed and sent to FAA. Name(s) of the contact person(s) responsible for corrective action: Melody Sauerhafer Planned completion date for corrective action plan: 09/30/2024

View Audit 323605

Finding 501547 (2023-002)

Material Weakness 2023

City of Avon Park

FL

Reporting Material Weakness

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City designate a responsible and qualified grant manager, establish internal controls for reporting, and file required reports in a timely and accurate manner. Explanation of disagree...

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City designate a responsible and qualified grant manager, establish internal controls for reporting, and file required reports in a timely and accurate manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Coronavius State and Local Fiscal Recovery Funds have all been depleted. The City is in the process of establishing interal controls for reporting and will review and file all future required reports in a timely and accurate manner. Name(s) of the contact person(s) responsible for corrective action: Melody Sauerhafer Planned completion date for corrective action plan: 09/30/2024.

View Audit 323605

Finding 501540 (2022-001)

Significant Deficiency 2023

Neighborhood Legal Services of Los Angeles County

CA

Reporting

July 29, 2024 The State Bar of California Office of Access and Inclusion 845 S. Figueroa Street Los Angeles, CA 90017 Neighborhood Legal Services of Los Angeles County (NLSLA) respectfully submits the following corrective action plan for the years ended December 31, 2022 and December 31, 2023 a...

July 29, 2024 The State Bar of California Office of Access and Inclusion 845 S. Figueroa Street Los Angeles, CA 90017 Neighborhood Legal Services of Los Angeles County (NLSLA) respectfully submits the following corrective action plan for the years ended December 31, 2022 and December 31, 2023 as a result of the Office of Access and Inclusion of the State Bar of California desk review of the Homelessness Prevention (HP) 3 Grants. Harrington Group Certified Public Accountants, LLP 2698 Mataro Street Pasadena, CA 91107 Audit period: January 1, 2022 – December 31, 2022; and January 1, 2023 – December 31, 2023 The findings from the 2022 and 2023 Schedule of Findings and Questioned Costs are discussed below. FINDING—FEDERAL AWARD PROGRAMS AUDITS Finding 2022-001 – Schedule of Expenditures of Federal Awards Reconciliation U.S Department of the Treasury Coronavirus State and Local Fiscal Recovery Funds—Assistance Listing No. 21.027 Significant Deficiency: The Schedule of Expenditures of Federal Awards (SEFA) was inaccurate and incomplete for the fiscal years-ended December 31, 2022 and 2023 as it did not include all programs that were federally funded. The original funding for the programs identified were not initially federally based. However, during COVID-19, the renewal of the programs continued through federal funding that were omitted from the SEFA reconciliation. Corrective Action: Under the direction of the Chief Financial Officer and as a new member of the fiscal team, the Director of Grants Management and Compliance will conduct a thorough review of all contracts, including renewal contracts, to confirm the funding source, whether NLSLA is the lead agency or a passthrough agency. If the renewal funding source is federally based, NLSLA will request a Notice of Federal Award to ensure proper inclusion in the annual SEFA and related Single Audit report. Under the direction of the Chief Financial Officer, the Controller will prepare the annual SEFA reconciliation to include all identified federally funded grants based on the contract agreements and provided Notice of Federal Awards. Person Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date for Corrective Action: The Corrective Action has been immediately implemented. If there are questions regarding this corrective action plan, please contact Lynne Hiortdahl, Chief Financial Officer, at (818) 291-1763 or LynneHiortdahl@nlsla.org. Sincerely, Lynne Hiortdahl Chief Financial Officer Recommendation: Implement procedures to designate management members responsible for the completion and accuracy of the SEFA. All government grants and contracts should be thoroughly reviewed to determine the funding source. Those identified as federal should be included in the SEFA. Neighborhood Legal Services of Los Angeles County | www.nlsla.org | Toll-Free Telephone: (800) 433-6251

View Audit 323595

Finding 501538 (2023-002)

Significant Deficiency 2023

Housing Authority of Sunnyside, Washington

WA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Views of responsible officials and planned corrective action: Management agrees with the finding and will implement the aforementioned recommendations. Ketha Kimbrough, Executive Director, will be responsible to implement this corrective action by December 31, 2024.

View Audit 323592

Finding 501506 (2023-003)

Significant Deficiency 2023

Family Christian Health Center

IL

Reporting

Finding: 2023‐003: Single Audit Reporting (Repeat 2022-004) The organization has hired a Controller with prior FQHC experience who is working diligently to resolve audit delays. The organization is now on target with completing audits before the 9 – month deadline after its fiscal year close. Re...

Finding: 2023‐003: Single Audit Reporting (Repeat 2022-004) The organization has hired a Controller with prior FQHC experience who is working diligently to resolve audit delays. The organization is now on target with completing audits before the 9 – month deadline after its fiscal year close. Responsible party: Controller Completion date: since July 2024

View Audit 323571

Finding 501499 (2023-003)

Significant Deficiency 2023

Puerto Rico Land Administration

PR

Reporting

In order to comply with the federal requirement, the Administration is standardizing the reporting process and defining the roles and responsibilities associated with these tasks to ensure that the Federal Financial Reports Standard Forms 425 (SF-425) are submitted as required. We expect to be in a...

In order to comply with the federal requirement, the Administration is standardizing the reporting process and defining the roles and responsibilities associated with these tasks to ensure that the Federal Financial Reports Standard Forms 425 (SF-425) are submitted as required. We expect to be in a position to comply with this requirement by the end of FY 2024-2025.

View Audit 323567

Finding 501497 (2023-001)

Significant Deficiency 2023

Puerto Rico Land Administration

PR

Reporting

The Administration will take steps to strengthen internal controls by developing guidelines and monitoring procedures for completing reports, and other tasks related to meet these requirements. As we recognize that this is an ongoing process, the program will continue to enforce policies and procedu...

The Administration will take steps to strengthen internal controls by developing guidelines and monitoring procedures for completing reports, and other tasks related to meet these requirements. As we recognize that this is an ongoing process, the program will continue to enforce policies and procedures by training all necessary staff on timeliness of procedure ensuring that the program fully complies with the monitoring process. Regarding the Single Audit for fiscal year 2024 the Administration have been working closely with the auditors to complete the submission of the Single Audit Report, which are expected to be finalized before the nine months after the 2024 fiscal yearend to be in compliance with the Uniform Guidance submission requirement.

View Audit 323567

Finding 501494 (2023-002)

Significant Deficiency 2023

Public Health - Madison and Dane County

WI

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal...

City of Madison Fire Department will coordinate with the City of Madison, Internal Audit and Grants function of the Finance Department, for an independent person to review the reports before submission to ensure the loss revenue calculation and amounts reported are accurate. This additional internal control procedure will ensure there are proper review and approval processes over completeness and accuracy of reports before submissions to federal agencies.

View Audit 323562

Finding 501493 (2023-003)

Significant Deficiency 2023

Public Health - Madison and Dane County

WI

Subrecipient Monitoring Reporting

On the 1st Quarter 2024 Quarterly Project and Expenditure (P&E) Report, the Grant Supervisor reported all expenditures related to the Revenue Recovery Replacement Category and submitted the report through the Treasury Portal. This correction was made prior to the auditor’s finding for 2023. Going fo...

On the 1st Quarter 2024 Quarterly Project and Expenditure (P&E) Report, the Grant Supervisor reported all expenditures related to the Revenue Recovery Replacement Category and submitted the report through the Treasury Portal. This correction was made prior to the auditor’s finding for 2023. Going forward, expenditures related to Revenue Recovery Replacement will be reported under Category 6 per the “Compliance and Reporting Guidance, State and Local Fiscal Recovery Fund”, dated March 28, 2024.

View Audit 323562

Finding 501253 (2023-003)

Material Weakness 2023

First Ame Housing Association

WA

HUD Housing Programs Reporting

Finding 2023-003 – Federal Award Finding Name of Official Responsible for Corrective Action: Earl Richardson, First AME Housing Association Interim Executive Director Corrective Action Planned: We appreciate the audit team's diligence in reviewing our financial processes and acknowledge the finding...

Finding 2023-003 – Federal Award Finding Name of Official Responsible for Corrective Action: Earl Richardson, First AME Housing Association Interim Executive Director Corrective Action Planned: We appreciate the audit team's diligence in reviewing our financial processes and acknowledge the finding related to the untimely reserve deposit. 1. Explanation: Example: "The delay in making the reserve deposit was primarily due to management not fully understanding HUD fund authorization per the HUD Handbook 4350. 2. Corrective Actions Taken: We have taken the following corrective actions: All reserve funds have been deposited in the appropriate reserve accounts at our bank. We have implemented a revised deposit schedule that will deposit reserve funds as required after receipt of direct deposit voucher payment from CMS. 3. Preventive Measures: To prevent a recurrence of this issue, we have instituted additional preventive measures, including producing monthly financial reports showing the deposits in a bank reconciliation line of the item and on the balance sheet. 4. Commitment to Compliance: We uphold the highest financial responsibility and compliance standards. Moving forward, we will remain vigilant to ensure timely reserve deposits and will continue to prioritize adherence to all relevant regulations and internal policies."

View Audit 323533

Finding 501252 (2023-002)

Material Weakness 2023

First Ame Housing Association

WA

HUD Housing Programs Reporting Eligibility

Finding 2023-002 – Federal Award Finding Name of Official Responsible for Corrective Action: Earl Richardson, First AME Housing Association Interim Executive Director Corrective Action Planned: Explanation: We acknowledge the oversight and would like to provide context to understand better the circu...

Finding 2023-002 – Federal Award Finding Name of Official Responsible for Corrective Action: Earl Richardson, First AME Housing Association Interim Executive Director Corrective Action Planned: Explanation: We acknowledge the oversight and would like to provide context to understand better the circumstances that led to the delay. We had internal challenges when our previous management company departed, leaving us with incomplete files and late recertifications or recertifications that never started, making it next to impossible to catch up promptly. Next, staff staffing issues contributed to the delays because staff members were not properly trained. Despite these challenges, we recognize the importance of adhering to HUD regulations and are committed to taking corrective measures. Corrective Actions Taken: We initiated immediate corrective actions to rectify the situation upon discovering the late recertifications. We have instituted the following measures to prevent the recurrence of late annual recertifications. 1. Created a recertification schedule and calendar with the annual recertification date, specific dates to notify residents that their annual recertification is due, and dates for submitting the information to CMS and to trac. The schedule and calendar are submitted to the executive director every two weeks to monitor progress, and a meeting is scheduled with staff every two weeks to review recertification issues. 2. We hired a consultant specializing in recertification to train the staff and work with staff daily to answer questions concerning our certification. This is not a one-anddone; our recertification consultant is permanently on call to answer certification issues and continuous staff training. These measures are designed to ensure timely compliance with HUD regulations and to strengthen our internal processes.

View Audit 323533

Finding 501236 (2023-002)

Material Weakness 2023

Mount Carmel Area School District

PA

Internal Control / Segregation of Duties Reporting

The Business Manager has year-end procedures in place to ensure year end adjusting entries are performed prior to the audit.

View Audit 323523

Finding 501234 (2023-002)

Significant Deficiency 2023

Trempealeau County

WI

Reporting Significant Deficiency

Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Paul L. Syv...

Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Paul L. Syverson, County Clerk Anticipated Completion Date: We will attempt to begin the multiple verification process for the 2024 calendar year

View Audit 323515

Finding 501230 (2023-001)

Material Weakness 2023

Logan Health

MT

Internal Control / Segregation of Duties Material Weakness Reporting

Finding 2023-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Federal Agency Name: Department of Health and Human Services Program Name: Activities to Support St...

Finding 2023-001 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Federal Agency Name: Department of Health and Human Services Program Name: Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Federal Assistance Listing: #93.391 Finding Summary: During the course of our engagement, we noted a material program missing from the Schedule that was not identified by management. Responsible Individuals: Kevin Abel, CEO and Brigid Burke, CFO Status: Procedures and controls over tracking and recording of federal programs with the Schedule will be updated in order to provide a complete Schedule. Anticipated Completion Date: 12/31/2024

View Audit 323504

Corrective Action Plans

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