Corrective Action Plans

Finding 499462 (2024-008)

Material Weakness 2024

LA

Questioned Costs Cash Management Subrecipient Monitoring § 200.305

2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper d...

2024-008 Cash Management Corrective action planned: Federal draws will be made with approval of the Director of Financial Operations or their designee for expenditures that have been incurred and recorded in the general ledger. Electronic documentation will be organized by draw to ensure proper documentation is maintained. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations

View Audit 322303 Questioned Costs: $1

Finding 499458 (2024-007)

Material Weakness 2024

Outpatient Medical Center, Inc.

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 1217745 (2023-003)

Material Weakness 2023

Head Start of Lane County

OR

Significant Deficiency Internal Control / Segregation of Duties

The agency has created new policies and implemented fail saifs, including board involvement, to ensure the deadlines for all required filing are met. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024

View Audit 403870

Finding 1217568 (2023-002)

Material Weakness 2023

Jumoke Academy, Inc.

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accoun...

The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accounting system and to ensure that the audit, Data Collection form, and reports are submitted timely.

View Audit 403718

Finding 1217208 (2023-001)

Material Weakness 2023

American Committee for Shaare Zedek Hospital in Jerusalem, Inc.

NY

Reporting Significant Deficiency Internal Control / Segregation of Duties

As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms w...

As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms will be submitted.

View Audit 403342

Finding 1215740 (2023-003)

Material Weakness 2023

Harvest Hope Food Bank

SC

Reporting Equipment & Real Property Management Subrecipient Monitoring

2023-003 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: S8lake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1215735 (2023-002)

Material Weakness 2023

Harvest Hope Food Bank

SC

Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management

2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-6...

2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635

View Audit 402412

Finding 1215384 (2023-002)

Material Weakness 2023

New Space Nexus

NM

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, ...

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, procurement, cash management, subrecipient monitoring, reporting, record retention, and internal controls. The Financial Analyst will be responsible for maintaining and updating these policies, with oversight from the Executive Director, and policies will be reviewed at least annually and updated as needed. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024

View Audit 401939

Finding 1215383 (2023-001)

Material Weakness 2023

New Space Nexus

NM

Eligibility Period of Performance Reporting

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as...

Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as required, and completed forms will be securely maintained and retained for the required period. The Financial Analyst will periodically review personnel files to confirm compliance, and any missing or incomplete forms will be addressed promptly with documentation of corrective actions retained. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst by: January 31st, 2024

View Audit 401939

Finding 1214810 (2023-004)

Material Weakness 2023

Neighborhood Medical Center, Inc.

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Cr...

FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Criteria: Uniform Guidance requires nonfederal entities to submit the reporting entity's Uniform Guidance reporting package, including the audit report and completed Federal Audit Clearinghouse (F AC) Data Collection Form, to the F AC within the earlier of 30 calendar days after receipt of the auditor's rep01ts or nine months after fiscal year-end (2 CFR 200. 512( a)). Timely submission of the reporting package is required to facilitate federal oversight of award compliance. Context: The condition was identified during Single Audit testing of reporting requirements applicable to the Health Center Cluster. Sampling was not utilized. Condition: The Center did not submit its required Uniform Guidance reporting package, including the reporting entity's audit report and the FAC Data Collection Form, within the required submission timeframe. Specifically, the Uniform Guidance audit and related FAC Data Collection Form were submitted after the earlier of (1) 3 0 calendar days after receipt of the auditor's reports or (2) nine months after the end of the reporting entity's fiscal year. Cause: Due to a delay in the compiling of records related to the audit, the Center was not in compliance with the reporting requirements. Effect or Potential Effect: Failure to submit the Uniform Guidance audit and F AC Data Collection Form timely increases the risk of noncompliance with Uniform Guidance reporting requirements and may result in delayed federal oversight, increased monitoring by the awarding agency, or the imposition of additional administrative conditions. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is a repeat finding. Recommendation: The Center should strengthen internal controls over Uniform Guidance audit reporting by ·implementing procedures to track submission deadlines, assigning responsibility for timely filing of the audit report and FAC Data Collection Form, and establishing management review processes to ensure compliance with Uniform Guidance reporting requirements. View of Responsible Officials: Neighborhood's prior auditor indicated just before time to begin the audit for FY2022; they would not be able to complete the audit because of staff sho1tages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 and 2023 audits have been completed. Engagement contract has been issued for the 2024 audit.

View Audit 401535

Finding 1208812 (2023-003)

Material Weakness 2023

Schoodic Institute at Acadia National Park

ME

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties

Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the i...

Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the indirect rate, will be formally documented and a copy of the documentation will be maintained in our records. Note, the audit finding was originally included in the 2022 single audit report completed in early 2025. Planned Implementation Date of Corrective Action: March 14, 2025. Persons Responsible for Corrective Action: Kirk Geadelmann, Finance Director Tyler Piebes, Bookkeeper Nick Fisichelli, President & CEO

View Audit 399694

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

Corrective Action Plans

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