Corrective Action Plans

Finding 499458 (2024-007)

Material Weakness 2024

LA

Allowable Costs / Cost Principles Material Weakness Reporting

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. ...

2024-007 Reporting (repeat of finding 2023-003) Corrective action planned: The new accounting system which OMC implemented in April 2024, allows for better tracking of UDS related costs, primarily financial related data. Documentation for UDS reporting will be maintained and updated when needed. Internal auditing has already been implemented to ensure compliance with reporting requirements. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Richard Bruce, Chief Operating Officer

View Audit 322303

Finding 497631 (2024-001)

Significant Deficiency 2024

Howard Payne University

TX

Questioned Costs Student Financial Aid Significant Deficiency

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FA...

Incorrect Return of Title IV Funds Calculation Planned Corrective Action: Extensive training on module (Summer, Summer 1, and Summer 2) refunds have been completed. Each summer refresher training will take place due to the complicated nature of summer module calculation. Students who complete FAFSA after a term will be reviewed to determine how much Title IV aid they are eligible to have disbursed. The R2T4 calculation will be processed to learn the percentage earned. Exception to the R2T4 will be if student completed the module/term successfully. Person Responsible for Corrective Action Plan: Karen LaQuey, Director of Student Financial Aid Anticipated Date of Completion: Immediately

View Audit 320424 Questioned Costs: $1

Finding 497459 (2023-001)

Significant Deficiency 2024

Community Action for Improvement, Inc.

GA

Significant Deficiency Internal Control / Segregation of Duties

2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year a...

2024-001 – Tri-Partite Board Composition Condition: At times during the year, less than 1/3 of the members of the board of directors of Community Action for Improvement, Inc. were representative of the low-income individuals and families served by the Organization. This is a repeat of prior year audit findings 2021-001, 2022-002 and 2023-001. Recommendation: We recommend that Community Action for Improvement, Inc. establish procedures to ensure the composition of the members of its board of directors meets this requirement. Corrective Action Plan: The Board of Directors for CAFI has a Membership Committee. Their role is to guide the recruitment and retention of Board members. At the time of this plan (8/16/24) all Board seats are filled. The Committee embarked on a Board Development Plan, lowered their Board seats, and worked hard to ensure a full Board. Person(s) Responsible: Board of Directors / Jennifer Corcione Timing for Implementation: Implemented by 9/01/2024.

View Audit 320245

Finding 496969 (2024-003)

Significant Deficiency 2024

Northland Health Partners Community Health Center

ND

Significant Deficiency Internal Control / Segregation of Duties

Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of...

Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.

View Audit 319712

Finding 496933 (2024-001)

Significant Deficiency 2024

Cccs Farm Labor Housing Corporation

CO

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. Th...

We concur with the observations and recommendations as placed forth by our auditors – KCM. As a result of employee turnover in fiscal year 2024, the company experienced difficulties completing certain forms. Since then, however, controls have been implemented to reduce the risk of noncompliance. These include the hiring of a new compliance manager and the cross-collaboration of three property accountants, with a master trial balance shared to support teammates when they are on vacation or turnover occurs. We will work to re/file these forms immediately and begin tracking their status to prevent inaccurate/untimely filing.

View Audit 319674

Finding 485406 (2024-002)

None 2024

Lincoln Christian University

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retain...

2024-002 Student Financial Aid – 84.268 – Federal Direct Loan Program, 84.063 – Federal Pell Grant Program, 84.007 – Federal Supplemental Educational Opportunity Grant Program, 84.033 – Federal Work-Study Program Recommendation: We recommend the review process for awarding be documented and retained as support for the review and approval process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Director of Financial Aid will document each change to an award by printing a new award offer and saving to document tracking. As this is the final year in which Lincoln Christian University will have academic operations, we believe this corrective action to be sufficient for the remainder of the year. Name of the contact person responsible for corrective action: Margie Martin, Director of Accounting Planned completion date for corrective action plan: May 31, 2024.

View Audit 318153

Finding 485338 (2024-001)

Significant Deficiency 2024

Berkshire Retirement Home INC

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to e...

Section 232 Mortgage Insurance for Nursing Homes – Assistance Listing No. 14.157 Recommendation: The auditor recommends that management increase their coverage amount to come into compliance with HUD requirements, as well as develop policies and procedures to monitor required coverage minimums to ensure that actual coverage amount is kept at least at that level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fidelity Bond insurance coverage was immediately increased from $1,135,927 to $1,182,615 to be above the minimum required threshold of $1,164,177 when identified. The new process implemented will assess potential organizational revenue growth ahead of insurance renewal to maintain at least the minimum required coverage threshold. Name(s) of the contact person(s) responsible for corrective action: Edward Forfa Planned completion date for corrective action plan: 8/12/2024

View Audit 318084

Finding 485172 (2024-002)

Significant Deficiency 2024

Regis University

CO

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...

Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.

View Audit 317977

Finding 485144 (2024-001)

Significant Deficiency 2024

East Central Kansas Economic Opportunity Corporation

KS

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit ...

August 20, 2024 Department of Housing and Urban Development Washington DC East Central Kansas Economic Opportunity Corporation respectfully submits the following corrective action plan for the year ended March 31, 2024. SSC CPAs, PA 3320 Clinton Parkway Court, Suite 120 Lawrence, KS 66047 Audit Period: Year ended March 31, 2024 The finding from March 31, 2024, schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS 2024-001 Compliance and Controls over Eligibility of the Section 8 Housing Choice Vouchers Program (Significant Deficiency) Federal Agency: U.S. Department of Housing and Urban Development Program Name: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: March 31, 2024 Recommendation: The Board of Directors and management review the controls over the eligibility process to ensure the process is being followed and implemented correctly. Action Taken (Unaudited): ECKAN will create a policy in its Admin Plan, using any new HOTMA rules that may apply, to require zero-income forms in client files for households claiming zero-income. This Admin Plan edit will be presented to the ECKAN Board of Trustees for approval. Effective immediately (as of date of file inspection) ECKAN will use the Zero Income Verification Form for any new families claiming zero income. This had been a practice within the department but had not been formalized or provided oversight. ECKAN will also take steps to ensure current client files are searched for any families who claimed zero income prior and either locate the form or initiate contact with the family to obtain a completed form. A tracking spreadsheet will be created to ensure a complete list of zero-income households is maintained and monitored by the ECKAN housing staff. Anticipated completion date is March 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please call Crystal Anderson at 785-242-7450. Sincerely yours, Crystal Anderson Crystal Anderson CEO East Central Kansas Economic Opportunity Corporation

View Audit 317959

Finding 479547 (2024-002)

Significant Deficiency 2024

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing...

Plan of Action: The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action:  Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application. The supervisor will also review the application to ensure that all signatures and demographic data has been included. o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 316096

Finding 478290 (2024-004)

Significant Deficiency 2024

Epsom Elderly Housing, Inc.

NH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing

View Audit 314973

Finding 478285 (2024-004)

Significant Deficiency 2024

Belmont Elderly Housing, Inc.

NH

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adju...

Plan: On June 4, 2024, the new Affordable Housing Director identified and corrected the incorrect authorized user information in the OneSite system with her own information. A protocol will be created for promptly updating authorized user information whenever there are personnel changes or role adjustments. Anticipated Completion Date: 06/04/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing

View Audit 314972

Finding 478174 (2024-001)

Significant Deficiency 2024

Village of Lawrence, Inc.

KS

HUD Housing Programs Reporting Significant Deficiency § 200.512

The Board of Directors will designate an individual to document financial statement preparation processes which ensure timely submission of the Single Audit Reporting Package.

View Audit 314842

Finding 477896 (2024-001)

Significant Deficiency 2024

Clinica Campesina Family Health Services

CO

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.

View Audit 314530

Finding 1208451 (2023-004)

Material Weakness 2023

Menard County, Illinois

IL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Effective 4/17/2026, the Menard County Board of Commissioners will review and approve all financial and performance reports prior to submission to both State and Federal funding sources.

View Audit 399426

Finding 1208283 (2023-004)

Material Weakness 2023

Aurora Homes, Inc.

MD

Eligibility HUD Housing Programs Significant Deficiency

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing

View Audit 399312

Finding 1208281 (2023-006)

Material Weakness 2023

Ashmore Homes, Inc.

MD

Special Tests & Provisions Eligibility HUD Housing Programs

Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - M...

Fund Account - Deposited back to the replacement reserve account - October 16, 2025 Segregation and Monitoring - Transfer all new deposits immediately; perform monthly reconciliations. - Effective immediately Policies and Training - Update policies; train staff on deposit handling and monitoring - May/June 2026 Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to Finance Committee - Ongoing

View Audit 399311

Finding 1208279 (2023-004)

Material Weakness 2023

Ashmore Homes, Inc.

MD

Eligibility HUD Housing Programs Significant Deficiency

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards,...

Tenant File Review - Review all tenant files; obtain and file missing documentation - May 2026 Policies and procedures - Update and document procedures; implement standardized checklist; supervisory review required. - May 2026 Staff Training - Train staff on HUD eligibility, documentation standards, and updated procedures Ongoing Monitoring - Quarterly internal audits; COO and Board Finance Committee review of compliance - ongoing Oversight and Reporting - CFO/Controller review monthly reconciliations; provide quarterly updates to finance committee - ongoing

View Audit 399311

Finding 1206683 (2023-005)

Material Weakness 2023

Homeless Resource Council of the Sierras

CA

Subrecipient Monitoring Significant Deficiency

We agree with this finding and will document approval for changes in budgets with subgrantees.

View Audit 398809

Finding 1206680 (2023-002)

Material Weakness 2023

Homeless Resource Council of the Sierras

CA

Reporting Significant Deficiency § 200.512

The Organization agrees with this finding. Additional staff have been assigned to support the accounting function.

View Audit 398809

Finding 1206523 (2023-012)

Material Weakness 2023

MacOmb County

MI

Eligibility Significant Deficiency Internal Control / Segregation of Duties

The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County i...

The County acknowledges deficiencies related to the availability and completeness of supporting documentation for one federal program expenditures and reporting. In some instances, supporting documentation was not readily available at the time of review or required additional follow-up. The County is strengthening documentation and record retention practices, improving coordination with program staff, and reinforcing expectations for maintaining complete and timely supporting records. These actions are intended to ensure documentation is available to support reporting and compliance requirements.

View Audit 398574

Finding 1206519 (2023-011)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges delays in the preparation and submission of certain required federal reports, including Statements of Expenditures. These delays were attributable to data availability, process inefficiencies during the ERP transition period, and the timing in which the Statement of Expenditu...

The County acknowledges delays in the preparation and submission of certain required federal reports, including Statements of Expenditures. These delays were attributable to data availability, process inefficiencies during the ERP transition period, and the timing in which the Statement of Expenditures template was provided by the grantor. In response, the County is improving internal workflows by enhancing coordination between program and finance staff, strengthening review procedures, and standardizing reporting processes. These actions are intended to improve both the accuracy and timeliness of reporting as processes continue to be refined within the system environment.

View Audit 398574

Finding 1206515 (2023-010)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges deficiencies related to the timeliness of federal reporting, including delays in the submission of required financial reports. Certain reports were not submitted within required timeframes due to challenges in obtaining timely and complete data, delays in completing reconcili...

The County acknowledges deficiencies related to the timeliness of federal reporting, including delays in the submission of required financial reports. Certain reports were not submitted within required timeframes due to challenges in obtaining timely and complete data, delays in completing reconciliations during and following the ERP transition, and the timing of required reporting templates provided by the grantor. The County is strengthening reporting procedures by improving coordination between departments, enhancing reconciliation processes, and reinforcing internal timelines for report preparation and review. As system functionality and staff familiarity continue to improve, reporting timeliness is expected to stabilize, with full resolution anticipated in the 2025 audit cycle.

View Audit 398574

Finding 1206511 (2023-009)

Material Weakness 2023

MacOmb County

MI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

The County acknowledges the deficiency related to ensuring expenditures charged to federal programs comply with allowable cost principles under Uniform Guidance. The transition to the Workday ERP system impacted established review processes and data availability. The County is strengthening internal...

The County acknowledges the deficiency related to ensuring expenditures charged to federal programs comply with allowable cost principles under Uniform Guidance. The transition to the Workday ERP system impacted established review processes and data availability. The County is strengthening internal controls by enhancing review and approval procedures and improving staff training. As system processes continue to be refined, compliance and documentation are expected to improve.

View Audit 398574

Finding 1206365 (2023-006)

Material Weakness 2023

Town of Livermore Falls

ME

Cash Management Significant Deficiency § 200.302 § 200.305

CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select...

CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and has implemented the new Internal Controls Policy that addresses this deficiency. This policy will includes sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: This was completed February 20, 2024.

View Audit 398382

Corrective Action Plans

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