Corrective Action Plans

Finding 402308 (2023-001)

Significant Deficiency 2023

Infinity Health

IA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.430

Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding...

Allowable Activities and Costs – Assistance Listing No. 93.224/93.527 Recommendation: CLA recommends that the Organization consider completing time and effort attestation forms electronically to ensure none get lost or misplaced and are returned timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Infinity Health’s current policy to support compliance with time and effort requirements is to obtain a statement from each employee with any time allocated for a grant, certifying the time spent on grant activities on a quarterly basis. Beginning 12/1/2023, Infinity Health has implemented a new electronic document management system which will improve our ability to track and monitor timely completion of time and effort statements each quarter. Name(s) of the contact person(s) responsible for corrective action: Kyle Ahlenstorf, CEO, and Michelle Leonard, CFO. Planned completion date for corrective action plan: June 30, 2024

View Audit 309894

Finding 401957 (2023-001)

Significant Deficiency 2023

Southern Nevada Regional Housing Authority

NV

HUD Housing Programs Subrecipient Monitoring Eligibility

Finding 2023 - 001: Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: Currently, we are having all HCV staff trained and refreshed on rent calculations through Nan McKay. Staff will also be...

Finding 2023 - 001: Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: Currently, we are having all HCV staff trained and refreshed on rent calculations through Nan McKay. Staff will also be trained in best practices for properly obtaining verification and following the verification hierarchy process. Also, we are hiring a Training and Development Specialist. Once filled, we will conduct monthly and quarterly training. We anticipate filling the position by July 2024. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Quality Control of 25% of all annuals and 25% of all interims completed monthly by all non provisional employees. Department Structure: The supervisors will quality-control any caseworkers with an error rate of 80% of their files. Once we fill all staff vacancies and complete the provisional period for all our new staff, we will audit up to 40% of all completed files. Anticipated Completion Date: The current staff is attending Nan McKay's rent calculations training on June 4-6, 2024. We anticipate completion of the plan by 12/31/2024. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, and Ms. Malandria Watson, Housing Program Manager I, will review the Quality Control Report and error ratios monthly.

View Audit 309875

Finding 401928 (2023-002)

Significant Deficiency 2023

East Phillips CO Hospital Dist Dba Melissa Memorial Hospital

CO

HUD Housing Programs Material Weakness Significant Deficiency

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensu...

Policies and Procedures for Federal Awards Corrective action planned: Management will consult an advisory firm to assist with providing sample policies and procedures for tracking and usage of federal awards. Management will review and implement policies and procedures no later than 60 days to ensure compliance with tracking and usage of federal awards. Anticipated completion date: June 30, 2024 Contact person responsible for corrective action: Angela St. John, CFO

View Audit 309848

Finding 401879 (2023-001)

Significant Deficiency 2023

The Trust for Tomorrow

NC

Internal Control / Segregation of Duties Cash Management Significant Deficiency

As noted above, The Trust for Tomorrow continues to add compensating controls each year when possible. For example, a Director of Financial Operations was hired during the last half of the fiscal year under audit and this individual has taken over certain responsibilities, including but not limited ...

As noted above, The Trust for Tomorrow continues to add compensating controls each year when possible. For example, a Director of Financial Operations was hired during the last half of the fiscal year under audit and this individual has taken over certain responsibilities, including but not limited to general ledger coding, review and approval of invoices, processing timesheets, and handling expense reimbursement requests. Further, we will continue to review our processes to determine where duties can be segregated amongst existing staff. Additionally, the board will continue to provide close oversight of the Organization and evaluate that oversight on a consistent basis.

View Audit 309790

Finding 401873 (2023-001)

Significant Deficiency 2023

Rowan County Housing Authority

NC

HUD Housing Programs Eligibility Reporting

Corrective Action Plan For the Year Ended September 30, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Sara Potts, Executive Director Corrective Action: We concur. Management will rev...

Corrective Action Plan For the Year Ended September 30, 2023 Section II - Financial Statement Findings None Reported Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Sara Potts, Executive Director Corrective Action: We concur. Management will review the internal control procedures as they relate to eligiblity and will implement procedures to ensure all documents are obtained during intake. Proposed Completion Date: Immediately.

View Audit 309773

Finding 401872 (2023-001)

Significant Deficiency 2023

American Academy McAllister Institute of Funeral Service, Inc.

NY

Special Tests & Provisions Student Financial Aid Significant Deficiency

May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1...

May 7, 2024 U.S. Department of Education American Academy McAllister Institute of Funeral Services, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Auditors: CohnReznick 1301 Avenue of the Americas New York, NY 10019 Audit period: October 1, 2022 to September 30, 2023 The findings from the fiscal year 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2023-001 Federal Direct Loan Program Student Recommendation: We recommended in the prior year that the Institute review and revise its procedures to put controls in place to ensure required notifications regarding Federal Direct Loan Program proceeds are provided to par-ticipating students. Action Plan: We agree with both the finding and the recommendation. In the Summer 2023 semester, a system was implemented to send out the required notifications regarding Federal Direct Loan Program proceeds that have been applied to a participating student's account. If the U.S. Department of Education has questions regarding this plan, please call Robert Graber at 732-547-9549.

View Audit 309770

Finding 401831 (2023-001)

Significant Deficiency 2023

Association of Prosecuting Attorneys, Inc.

DC

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Eligibility

Finding Reference Number: 2023-001 – Significant Deficiency – Lack of Documentation of Verification of Vendors Description of Finding: APA verified vendor was neither suspended nor debarred and staff confirmed as such in writing. However, they did not print and/or maintain a copy of the screenshot f...

Finding Reference Number: 2023-001 – Significant Deficiency – Lack of Documentation of Verification of Vendors Description of Finding: APA verified vendor was neither suspended nor debarred and staff confirmed as such in writing. However, they did not print and/or maintain a copy of the screenshot for files. This was inconsistent with APA written procedures. Statement of Concurrence (or Nonconcurrence): Management concurs that there was one instance wherein it did not print and maintain the verification screenshot for its files. Corrective Action: Management will review and update its procurement procedures to include a contract review checklist to be signed and dated by the preparer and approved by the contract signer (General Counsel, COO or CEO). Said checklist will include a specific reference to the date suspension and debarment were checked and will serve as primary documentary support which will be included in the vendor contract files. Contact Information: For further details or questions regarding this corrective action plan, please contact: Name: Steven Naugle

View Audit 309743

Finding 401797 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Charlestown

IN

HUD Housing Programs Significant Deficiency

June 14th, 2024 Findings- Major Federal Award Programs Audit- Corrective Action Plan (CAP) Public Housing Capital Fund finding 2023-001 For the year ended September 30th, 2023, the audit conducted by Cherry Bekaert LLP found Significant Deficiency, Nonmaterial Noncompliance- Obligation and Expenditu...

June 14th, 2024 Findings- Major Federal Award Programs Audit- Corrective Action Plan (CAP) Public Housing Capital Fund finding 2023-001 For the year ended September 30th, 2023, the audit conducted by Cherry Bekaert LLP found Significant Deficiency, Nonmaterial Noncompliance- Obligation and Expenditure Verification for public housing capital fund grant. The recommendation to implement controls to ensure capital grants are fully obligated by contractual agreements and expended within the required deadlines will be put into procedure by management of the Housing Authority. Management understands the importance of obligating and expending capital fund grants and to remedy the above deficiency, the Housing Authority will take an approach that will implement controls within regulations. -The Charlestown Housing Authority will review 24 CFR 905.306 {a) and 24 CFR 905.306 (F), and other regulations required for compliance with capital funds. - The Charlestown Housing Authority will implement internal checks and balances when obligatlng and expending funds for grants to ensure timely contracts and expenditures. - The Housing Authority will obligate capital funds prior to the 24-month deadline and expend the funds within the 48-month deadline. Responsible Person: Leigh Bowyer Completion Date of CAP: 6/13/24

View Audit 309699

Finding 401719 (2023-001)

Significant Deficiency 2023

Northern Regional Hospital

NC

Reporting Significant Deficiency Internal Control / Segregation of Duties

2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer. Explanation of disagreement with audit finding: Th...

2023-001 Provider Relief Funding – Assistance Listing No. 93.498 Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Northern Regional Hospital will adopt a policy to review all expenditures recorded and all submissions of reporting prior to the submission being made. This review will be done by someone independent of completing the preparation and will be documented as such. Name(s) of the contact person(s) responsible for corrective action: Derek White, Director of Operational Finance Planned completion date for corrective action plan: 6/30/24 If the Department of Health and Human Services has questions regarding this plan, please call Derek White, Director of Operational Finance at 336-719-7283.

View Audit 309652

Finding 401662 (2023-001)

Significant Deficiency 2023

Troy University

AL

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Co...

Corrective Action Plan The University will consistently follow established procedures used to perform Title IV refund calculations for students who withdraw after the 60 percent point that comply with Title 34 of the Code of Federal Regulations, Part 668.22. Anticipated Completion Date; June 2024 Contact Person(s): Alicia Bookout Associate Vice Chancellor, Financial Aid

View Audit 309623

Finding 401552 (2023-008)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

Questioned Costs HUD Housing Programs Significant Deficiency

Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagre...

Special Tests – Formula Income – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority reviews their controls over submitting forms to HUD to ensure they contain accurate information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New CFO is preparing a Subsidy Calculation procedure so new staff will be aware of what is eligible and non-eligible transactions for preparing forms. Name(s) of the contact person(s) responsible for corrective action: Shannon Sterling and/or Carlton Brown

View Audit 309583 Questioned Costs: $1

Finding 401551 (2023-007)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program lev...

Allowable Costs – Operating Fund – Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend the Authority establishes procedures to properly reconcile the revolving fund cash account to ensure that cash and interprogram accounts are properly reported at the program level. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: There are procedures in place to settle interfunds if possible. Name(s) of the contact person(s) responsible for corrective action: J Daniels and Shannon Sterling

View Audit 309583

Finding 401549 (2023-006)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Reporting Significant Deficiency

Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with au...

Reporting – PIC – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the person assigned to submit the 50058s to PIC assures a quality control review is performed on the submissions to ensure timely and accurate reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Following CLA’s recommendation, SVP of Housing Choice will audit a random sample of 50058 submissions to PIC each month to ensure that all submissions are accurate in PIC. Additionally, the Agency is transitioning to Yardi software which should eliminate many of the submission issues caused by current enterprise software. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401545 (2023-004)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Eligibility Significant Deficiency

Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the ...

Special Tests – Top of the Waiting List – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that the Authority reviews their standard procedures to ensure requests for informal reviews are granted and notified to the applicant within 30 days of the receipt of the request. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency hired a dedicated Hearing Officer following last year’s audit. Unfortunately, during the period in question, the Hearing Officer went on maternity leave and then subsequently left the position resulting in a delay in completing hearings and reviews. The Agency has since contracted with a 3rd party to conduct hearings and reviews in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401543 (2023-003)

Significant Deficiency 2023

The Housing Authority of East Baton Rouge Parish

LA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanatio...

Special Tests – Annual HQS and Quality Control Inspections – Housing Voucher Cluster – Assistance Listing No. 14.871 Recommendation: We recommend that management review their controls for conducting HQS biennial and quality control re-inspections and ensure compliance standards are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previously, staff used a 90-day window to select Quality Control samples. Doing so caused some QC inspections to be completed past the regulatory time period. Going forward, staff are selecting the sample size from a 45-day window. This allows sufficient time to complete the QC inspection within the regulatory time period. Name(s) of the contact person(s) responsible for corrective action: Janie Anderson, VP Housing Voucher Cluster Planned completion date for corrective action plan: September 30, 2023

View Audit 309583

Finding 401542 (2023-002)

Significant Deficiency 2023

Goodwill Industries of Greater Cleveland and East Central, Ohio, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

In 2024 the manual component of the calculations has been eliminated and all calculations of billing units are now completed using an Excel spreadsheet.

View Audit 309574 Questioned Costs: $1

Finding 401511 (2023-001)

Significant Deficiency 2023

Vita Nova, Inc.

FL

HUD Housing Programs Special Tests & Provisions Significant Deficiency

May 22, 2024 Vita Nova, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Holyfield & Thomas, LLC, 125 Butler Street, West Palm Beach, FL 33407 Audit period: For the fiscal year ended Septembe...

May 22, 2024 Vita Nova, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2023. Name and address of independent public accounting firm: Holyfield & Thomas, LLC, 125 Butler Street, West Palm Beach, FL 33407 Audit period: For the fiscal year ended September 30, 2023. The findings from the September 30, 2023 schedule of findings and questions costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD) 2023-001 Significant deficiency for the Continuum of Care Program, Youth Homeless Demonstration Program (YHDP) – Assistance Listing No. 14.267. Recommendation: We recommend that when the rent reasonableness worksheet reflects that the proposed rent is not reasonable, the lease contracts should not be approved, and negotiations should begin with the landlord to get the rent within the reasonable range. To ensure this step is taken, we recommend that the Program Director review, and initial each rent reasonableness worksheet before the lease is signed for the client tenant. Action Taken: In September 2023, Vita Nova reassigned the YHDP program to the oversight of a new Director of Housing. In late October 2023, the new Director identified the specified issue as part of a detailed file review and immediately took action to correct this error. New lease agreements were established with both tenants as of November 2, 2023, using rent reasonable rates. Vita Nova has since taken additional steps to ensure this and other similar errors do not reoccur as follows: • Housing Case Managers are not authorized to complete rent reasonableness worksheets. This procedure is completed directly by the Director of Housing. • If the requested rent is found to not be reasonable, the Director of Housing initiates negotiations with the landlord. • If rent reasonable rates are not able to be negotiated, the lease will not be signed. • The Director of Housing approves all lease contracts and related rental costs. • Peer file reviews are conducted by Housing Case Managers (HCM) on a monthly basis, and review sheets are submitted to the Director of Housing. The Director of Housing then completes a follow-up internal review and returns any comments to the respective HCM(s) with a correction date for any needed revisions within 7 days. If the U.S. Department of Housing and Urban Development (HUD) has any questions regarding this plan, please call Kelly Landrum, Chief Operating officer at (561) 517-0040. Respectfully, Kelly A. Landrum Chief Operating Officer

View Audit 309564

Finding 401463 (2023-001)

Significant Deficiency 2023

Housing Authority of the County of Merced

CA

HUD Housing Programs Reporting Significant Deficiency

1. Finding 2023-001 a. Comments on the Finding and Each Recommendation: The Authority concurs with the finding. Additionally, we agree with the recommendations. b. Action(s) Taken or Planned on the Finding To address the significant deficiency in HQS re-inspections, we will immediately implement a s...

1. Finding 2023-001 a. Comments on the Finding and Each Recommendation: The Authority concurs with the finding. Additionally, we agree with the recommendations. b. Action(s) Taken or Planned on the Finding To address the significant deficiency in HQS re-inspections, we will immediately implement a streamlined scheduling and tracking system to ensure timely re-inspections and compliance with 24 CFR Part 982. Additionally, we have since replaced the staff member responsible for the non-compliance and reassigned these responsibilities to another department staff member to better allocate resources and talent to prioritize HQS re-inspections.

View Audit 309554

Finding 401449 (2023-101)

Significant Deficiency 2023

Central Arizona Shelter Services, Inc.

AZ

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles

Management agrees with this finding. CASS does not have any subrecipients. However, if CASS has subrecipients in the future, comprehensive written policies and procedures will be in place to ensure all subrecipients payments are made on a timely basis and all required documentation and communication...

Management agrees with this finding. CASS does not have any subrecipients. However, if CASS has subrecipients in the future, comprehensive written policies and procedures will be in place to ensure all subrecipients payments are made on a timely basis and all required documentation and communications will be retained as result of missing or inaccurate information in the subrecipient’s drawdown requests prior to remittance.

View Audit 309553

Finding 401430 (2023-001)

Significant Deficiency 2023

Harrison County, Mississippi

MS

Reporting Significant Deficiency Program Income

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Report...

CORRECTIVE ACTION PLAN 2023-001 Item 2023-001 Significant Deficiency in Internal Control over Compliance Program Coronavirus State and Local Fiscal Recovery Fund, Assistance Listing 21.027 Compliance Requirement Reporting Criteria The U.S. Department of Treasury SLFRF Compliance and Reporting Guidance requires the County prepare quarterly submissions of the Project and Expenditure Report. The 2023 Compliance Supplement identifies multiple Key Line Items in the report, including cumulative expenditures and current period expenditures. Internal control should be established and maintained to provide reasonable assurance that these requirements are complied with by submitting the reports accurately. Condition For the fiscal year under audit, the Project and Expenditure Report reported cumulative expenditures as program income, and the total obligation was reported as cumulative expenditures before the amounts had actually been spent. This was noted on the first two quarterly reports, but the last two quarterly reports were corrected. Cause The County followed a process for reviewing the reports and understanding program requirements; however, the new and emerging nature of the program and related guidance limited the internal knowledge necessary to identify the errors. Effect Required reports submitted to the Federal Agency contained inaccuracies to identified key elements. Recommendation We recommend that the County expand its review process for key reports to consider if new or emerging funding merits additional staff training or the engagement of outside assistance. PERSON RESPONSIBLE FOR CORRECTION ACTION: Becky Haynes, County Auditor CORRECTIVE ACTION PLANNED: We agree with the finding and have initiated discussions to provide training and implement procedures to ensure compliance. We have made these changes during the fiscal year, where the last two quarterly reports were properly stated . ANTICIPATED COMPLETION DATE: September 30, 2023. See prior year finding 2022-001.

View Audit 309550

Finding 401413 (2023-001)

Significant Deficiency 2023

Boulder Crest Foundation

VA

Cash Management Reporting Significant Deficiency § 200.61

Corrective Action Plan For the year ended December 31, 2023 Identifying Number: 2023-001 Finding: The overall process for tracking federal funds spent and the reimbursement process is a manual process performed by one department. The Foundation lacks formal policies for reimbursement and timely...

Corrective Action Plan For the year ended December 31, 2023 Identifying Number: 2023-001 Finding: The overall process for tracking federal funds spent and the reimbursement process is a manual process performed by one department. The Foundation lacks formal policies for reimbursement and timely review of calculations throughout the year. Corrective Action Taken or Planned: Management is actively working with the awarding agencies to fully understand the compliance requirements and implement appropriate policy and process to administer the federal programs. Management is reviewing the current procedures and formalizing the process for tracking and reporting of federal funds. The responsible individuals for the plan are the Chief Executive Officer and Controller.

View Audit 309540

Finding 401406 (2023-001)

Significant Deficiency 2023

Community Mental Health Partnership of Southeast Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties Significant Deficiency § 200.332

Corrective Action Plan Finding: 2023-001 – Communications with Subrecipients (repeat comment) Condition: Contracts with subrecipients did not include portions of required disclosures. Corrective Action Plan: CMHPSM added an additional staff position, Regional Project Assistant, to do additional w...

Corrective Action Plan Finding: 2023-001 – Communications with Subrecipients (repeat comment) Condition: Contracts with subrecipients did not include portions of required disclosures. Corrective Action Plan: CMHPSM added an additional staff position, Regional Project Assistant, to do additional work on contracts. This position was added after the April 2023 Board meeting to assist with contract reviews. The position reports up to CJ Witherow.

View Audit 309525

Finding 401401 (2023-001)

Significant Deficiency 2023

Neighborhood Healthsource

MN

Reporting Significant Deficiency

Finding # 2023-001 Condition The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Response The Fede...

Finding # 2023-001 Condition The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Response The Federal Financial Report was filed late in 2023 due to an extended vacancy of a key finance position. The position has now been filled and should not be an issue going forward. Responsible Party Curt Engels, Finance Director Estimated Completion On-going

View Audit 309519

Finding 401370 (2023-001)

Significant Deficiency 2023

Lake Area Improvement Corporation

SD

Significant Deficiency Internal Control / Segregation of Duties

Action Plan for Addressing Audit Finding on Intermediary Relending Program (IRP) Funds 1. Introduction Purpose: To address the audit finding regarding the Intermediary Relending Program (IRP) funds that were not fully insured by the Federal Deposit Insurance Corporation (FDIC) and to implement cor...

Action Plan for Addressing Audit Finding on Intermediary Relending Program (IRP) Funds 1. Introduction Purpose: To address the audit finding regarding the Intermediary Relending Program (IRP) funds that were not fully insured by the Federal Deposit Insurance Corporation (FDIC) and to implement corrective actions to ensure compliance with U.S. Department of Agriculture requirements. Scope: This action plan focuses on ensuring that all reserves and cash in the IRP revolving fund are fully insured or collateralized with U.S. Government obligations, as outlined in 7 CFR Part 4274.332(b). 2. Audit Findings Summary Finding: IRP funds on deposit with a local financial institution were not fully insured by the FDIC. Questioned Costs: None. Criteria: U.S. Department of Agriculture requires all reserves and cash in the IRP revolving fund to be fully insured or collateralized. Cause: Management was aware of the requirement but inadvertently overlooked it due to an influx of cash received during the year. Effect: Inadequate internal controls over compliance could result in noncompliance with grantor agency requirements and jeopardize LAIC’s continued participation in the program. Recommendation: Management should be aware of all program requirements and take appropriate action to correct deficiencies. 3. Action Steps Action Step 1: Review and Understand Program Requirements Finding Addressed: Lack of full insurance or collateralization of IRP funds. Description: Conduct a comprehensive review of 7 CFR Part 4274.332(b) and related requirements to ensure both team members and board of directors understand the compliance obligations. Responsible Person: Executive Director Resources Needed: Access to relevant regulatory documents, training materials. Timeline: Complete review and training by July 15, 2024. Success Criteria: All relevant staff have reviewed the regulations and can demonstrate understanding of the requirements. Action Step 2: Implement Monitoring and Controls Finding Addressed: Inadequate internal controls over compliance. Description: Develop and implement internal controls to monitor the insurance and collateralization status of IRP funds regularly. Responsible Persons: Executive Director and Administrative Assistant Resources Needed: Financial monitoring and monthly reviews. Timeline: Controls implemented by July 31, 2024. Success Criteria: Regular monitoring reports indicating compliance with insurance and collateralization requirements. Action Step 3: Secure Additional Insurance or Collateralization Finding Addressed: IRP funds not fully insured by the FDIC. Description: Ensure all IRP funds on deposit are either fully insured by the FDIC or collateralized with U.S. Government obligations. Responsible Persons: Executive Director and Administrative Assistant Resources Needed: Coordination with local financial institutions, legal advice if needed. Timeline: Complete by September 1, 2024. Success Criteria: Documentation showing that all IRP funds are fully insured or collateralized. Action Step 4: Regular Reporting to Board of Directors Finding Addressed: Inadequate internal controls over compliance. Description: Establish a regular reporting through monthly financials to update governance on the status of IRP fund compliance. Responsible Person/Team: Administrative Assistant Resources Needed: Reporting template, monthly meeting schedules. Timeline: Start regular reporting by September 26, 2024 Success Criteria: Monthly reports submitted to board of directors, with compliance status and any issues addressed. 4. Monitoring and Reporting Monitoring Process: Progress will be monitored through regular monthly meetings and monthly internal audits. Reporting Frequency: Monthly reports to board of directors. Responsible Person/Team: Executive Director and Administrative Assistant 5. Review and Adjustments Review Schedule: The action plan will be reviewed quarterly to assess progress and make necessary adjustments. Adjustment Process: Adjustments will be based on feedback from internal audits and progress reports, with updates approved by board of directors. 6. Conclusion Summary: This action plan outlines the steps to address the audit finding regarding the IRP funds and to ensure full compliance with USDA requirements. Commitment: LAIC is committed to implementing these actions to enhance internal controls, ensure compliance, and maintain continued participation in the IRP program. _________________________________________________________ Brooke Rollag, Executive Director

View Audit 309466

Finding 401348 (2023-003)

Significant Deficiency 2023

Marygrove Non-Profit Housing Corporation II

MI

Special Tests & Provisions Allowable Costs / Cost Principles HUD Housing Programs

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Replacement Reserve Account Finding Type. Immaterial noncompliance; Significant def...

Corrective Action Plan Marygrove Nonprofit Housing Corp II, dba McGivney Bethune Apartments Project No. 044-EE011 Year Ended December 31, 2023 June 20, 2024 FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-003 – Replacement Reserve Account Finding Type. Immaterial noncompliance; Significant deficiency in internal control over compliance (Special Tests and Provisions) Federal programs U.S. Department of Housing and Urban Development  Supportive Housing for the Elderly (CFDA# 14.157) Condition. The replacement reserve balance was not maintained in an interest-bearing account. Effect. As a result of this condition, the reserve for replacements account was underfunded during 2023 as no interest was earned. Plan. Management agrees with finding 2023-003 and has developed the following plan. Management will request a waiver from HUD for the interest-bearing requirement on the project’s reserve account due to the fees charged by Bank of America, which will exceed any interest earned on the account. Contact Person Responsible for This Corrective Action: David DeFrain, Vice President of Finance Anticipated completion date: June 30, 2024

View Audit 309440

Corrective Action Plans

Filters