Corrective Action Plans

Finding 208 (2022-003)

Material Weakness 2022

County of Mifflin

PA

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

Material Weakness Reporting Internal Control / Segregation of Duties § 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 185 (2022-005)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

HUD Housing Programs Subrecipient Monitoring Reporting

Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 a...

Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD

View Audit 281

Finding 184 (2022-004)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

HUD Housing Programs Subrecipient Monitoring Reporting

Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Fina...

Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD

View Audit 281

Finding 178 (2022-001)

Material Weakness 2022

Guam Housing and Urban Renewal Authority

GU

Subrecipient Monitoring HUD Housing Programs Reporting

Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects ...

Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects transactions using the accrual basis method of accounting. Due to the differing accounting methods, variances are expected between reports extracted from IDIS and GHURA’s accounting system. The responsible party will prepare a reconciliation between GHURA’s trial balance and the IDIS reports to ensure the completeness and accuracy of the reported amounts. GHURA agrees with the recommendation to monitor subawards for reporting in FSRS. Responsible Party: Katherine Taitano, Chief Planner, and Jerricho Garcia, General Accounting Supervisor Anticipated Date of Completion: September 30, 2024

View Audit 281

Finding 125 (2022-001)

None 2022

Maimonides Medical Center

NY

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 122 (2022-005)

Significant Deficiency 2022

Killdeer Public School District No. 16

ND

Reporting

Contact Person: Rhonda Zastoupil, Business Manager, Planned Corrective Action: The District will implement the auditor's recommendation. Planned Completion Date: March 31, 2024

View Audit 180

Finding 90 (2022-004)

None 2022

County of Richland

WI

Reporting

2022-004 Late Submission of 2021 Data Collection Form to Federal Audit Clearinghouse Condition: The 2021 data collection form for the County was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: The Fe...

2022-004 Late Submission of 2021 Data Collection Form to Federal Audit Clearinghouse Condition: The 2021 data collection form for the County was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: The Federal Audit Clearinghouse requires that organizations submit their annual audit and the annual data collection form within nine months after the fiscal year-end. Cause: The delay in submitting the 2021 data collection form and the 2021 annual audit was primarily due to audit was completed late. Effect: This delay in submission may hinder timely access to accurate financial information for decision-making and reporting. Auditor’s Recommendation: We recommend that the County establishes a formalized process to track regulatory filing deadlines and responsibilities and conduct periodic reviews to ensure timely compliance with regulatory requirements. Management Response: The County acknowledges the audit finding and commits to implementing the recommended actions promptly to enhance compliance with regulatory requirements regarding data collection form submissions. Contact Person: Derek Kalish Anticipated Completion: Ongoing

View Audit 110

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

Material Weakness Reporting Matching / Level of Effort / Earmarking § 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 30 (2022-004)

Significant Deficiency 2022

Region III Workforce Investment Board of Kanawha County, Inc.

WV

Reporting

With recent changes in Leadership, the Board of Directors has established committees for financial policy and a robust internal control system, and as a result, an initiative is underway for the establishment of expenditure policies. We expect to have the new expenditures policy and Financial Manual...

With recent changes in Leadership, the Board of Directors has established committees for financial policy and a robust internal control system, and as a result, an initiative is underway for the establishment of expenditure policies. We expect to have the new expenditures policy and Financial Manual approved by the Board at the next Board Meeting in October.

View Audit 56

Finding 6 (2022-002)

None 2022

Region III Workforce Investment Board of Kanawha County, Inc.

WV

Reporting

The prior audit (for FY 2021) had been delayed, and the Board determined that it was time to issue an RFP to consider other auditors. With the late completion of the prior audit, and the selection of a new auditor, there was insufficient time to engage the new firm to commence the audit and complete...

The prior audit (for FY 2021) had been delayed, and the Board determined that it was time to issue an RFP to consider other auditors. With the late completion of the prior audit, and the selection of a new auditor, there was insufficient time to engage the new firm to commence the audit and complete it and submit the Single Audit prior to the deadline.

View Audit 56

Finding 1205883 (2021-003)

Material Weakness 2021

City of Newark

NJ

Reporting

It is recommended that Management should ensure information is accessible and available for audit. Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date - December 31, 2023

View Audit 397668

Finding 1205748 (2021-003)

Material Weakness 2021

Rocky Mountain Tribal Leaders Council

MT

Reporting

RMTLC plans to learn the current government system for Federal Financial Report (FFR) reporting and accessing general ledger reports. The new system was implemented in 2025 under new administration and affected all previous funding prior to 2025. Therefore, some of those duties that we are dealing w...

RMTLC plans to learn the current government system for Federal Financial Report (FFR) reporting and accessing general ledger reports. The new system was implemented in 2025 under new administration and affected all previous funding prior to 2025. Therefore, some of those duties that we are dealing with, such as timely completion of financial close and the reporting process, has been lacking. The recently hired CPA has training and will help correct this issue.

View Audit 397476

Finding 1205746 (2021-002)

Material Weakness 2021

Rocky Mountain Tribal Leaders Council

MT

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 1181990 (2021-008)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 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 1179948 (2021-003)

Material Weakness 2021

ADAMS COUNTY PUBLIC HOSPITAL DISTRICT #3 D/B/A OTHELLO COMMUNITY HOSPITAL

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.

View Audit 392296

Finding 1179947 (2021-002)

Material Weakness 2021

ADAMS COUNTY PUBLIC HOSPITAL DISTRICT #3 D/B/A OTHELLO COMMUNITY HOSPITAL

WA

Reporting Significant Deficiency § 200.512

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.

View Audit 392296

Finding 1177796 (2021-012)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.327

2021-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as de...

2021-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as defined under policy. 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 1177795 (2021-011)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.305

2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...

2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. 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 1177793 (2021-009)

Material Weakness 2021

St. Croix Chippewa Housing Authority

CA

Reporting

2021-009 Late Audit Submission Material Weakness Recommendation: Ensure your books are closed in a timely fashion and schedule audit work to begin early enough so that your reporting package will be submitted on time. Action Taken: The Housing Authority agrees with this finding and will implement th...

2021-009 Late Audit Submission Material Weakness Recommendation: Ensure your books are closed in a timely fashion and schedule audit work to begin early enough so that your reporting package will be submitted on time. 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 1176727 (2021-001)

Material Weakness 2021

Chuloonawick Native Village

AK

Allowable Costs / Cost Principles Reporting

Chuloonawick Native Village agrees with the finding and will retain documentation supporting its expenditures for subsequent audits and train all new staff correct filing procedures.

View Audit 390654

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

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

Finding 1176707 (2021-004)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Period of Performance

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Defi...

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.

View Audit 390602

Finding 1176706 (2021-003)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology ...

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology with full underlying documentation in line with PRF reporting requirements.

View Audit 390602

Corrective Action Plans

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