Corrective Action Plans

Finding 393177 (2023-001)

Significant Deficiency 2023

KY

HUD Housing Programs Eligibility Significant Deficiency

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and pr...

Recommendation: The design of the current controls should be reviewed to ensure tenant files are accurate, complete, and orderly and include a checklist of required documentation and retention guidelines. Procedures should also be established to ensure that the Form 50059 is completed timely and properly executed. The documentation in the files should support the data used in preparing the Form 50059 and calculating the tenant’s share of the rent. Action Taken: Management has started the process of reviewing, revising, streamlining and educating all staff on the HUD guidelines related to tenant file documentation requirements and proper completion of the Form 50059, including the documentation required to support the rent calculations.

View Audit 303499

Finding 393171 (2023-001)

Significant Deficiency 2023

Washington Adventist University

MD

Questioned Costs Student Financial Aid Special Tests & Provisions

We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process ...

We recently completed the transition and onboarding of departmental staff which would allow the University to fully enact its plan to ensure both the financial aid and the Registrar's office will perform prompt review of processing University withdrawals. The Registrar's office will develop process and procedures documentation as an internal control measuring tool to ensure that Administrative Withdrawals (AW) and Withdrawals for lack of attendance (WA) that affect student emollment are identified immediately. Staff in the Financial Aid and the Registrar's office will actively take part in training workshops and webinars provided by the Depatiment of Education and NASF AA for continuing education to stay abreast of new developments and best practices in the industry.

View Audit 303492 Questioned Costs: $1

Finding 393078 (2023-001)

Significant Deficiency 2023

Taylor County, Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding 2023‐001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not revie...

Finding 2023‐001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County’s quarterly performance reports submitted to the Department of Treasury were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County experienced personnel openings in FY 2023 for the position anticipated to prepare this report. Taylor County will continue to have the County Auditor prepare the performance reports, with a mechanical review of the report performed by an individual within the Auditor’s Office. Anticipated Completion Date: 04/30/2024 (Next reporting deadline)

View Audit 303417

Finding 393055 (2023-003)

Significant Deficiency 2023

Interfaith Works, Inc.

MD

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

Views of Responsible Officials: IW is utilizing a procedure to ensure that procured units are compliant with rent reasonableness standards. Currently, the Housing Locator identifies rental units of similar size and within a similar geographic region. The asking rental cost for each unit is compared ...

Views of Responsible Officials: IW is utilizing a procedure to ensure that procured units are compliant with rent reasonableness standards. Currently, the Housing Locator identifies rental units of similar size and within a similar geographic region. The asking rental cost for each unit is compared to the daily FMR rate. Based on the audit results we have revised this procedure to include documentation of this process in a spreadsheet. The unit once chosen by the client will be clearly indicated. The rent reasonableness rate during the selection period will also be indicated on the spreadsheet.

View Audit 303346

Finding 393051 (2023-001)

Significant Deficiency 2023

Myers Senior Residence, Inc. Hud Project No. 031-Ee074

NJ

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

UNDEFUNDING OF THE RESERVE RECOMMENDATION: WE RECOMMEND THAT MANAGEMENT TAKE THE NECESSARY STEPS TO ENSURE THAT FUTURE DEPOSITS ARE MADE IN ACCORDANCE WITH HUD REGULATION. PAYMENTS SHOULD BE MADE MONTHLY INTO THE REPLACEMENNT RESERVE. THERE IS NO DISAGREEMENT WITH THE AUDIT FINDING. ACTION PLANNE...

UNDEFUNDING OF THE RESERVE RECOMMENDATION: WE RECOMMEND THAT MANAGEMENT TAKE THE NECESSARY STEPS TO ENSURE THAT FUTURE DEPOSITS ARE MADE IN ACCORDANCE WITH HUD REGULATION. PAYMENTS SHOULD BE MADE MONTHLY INTO THE REPLACEMENNT RESERVE. THERE IS NO DISAGREEMENT WITH THE AUDIT FINDING. ACTION PLANNED IN RESPONSE TO FINDING: THE PROJECT'S OPERATING SYSTEM AND ANNUAL PROCEDURES ARE BEING ADDRESSED TO COMPLY WITH HUD. NAME OF THE CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: JOHN WESTERVELT, PRESIDENT PLANNED COMPLETION DATE FOR CORRECTIVE ACTION PLAN: JANUARY 31, 2024

View Audit 303332

Finding 392987 (2023-004)

Significant Deficiency 2023

Woodford County, Illinois

IL

Procurement, Suspension & Debarment Significant Deficiency

The County will ensure that businesses are registered and in good standing with SAM.gov prior to entering any contracts over $25,000.

View Audit 303308

Finding 392958 (2023-004)

Significant Deficiency 2023

Harris County- 7 Month Audit

TX

Questioned Costs Eligibility Significant Deficiency

HCSO agrees with the audit finding regarding our lack of documentation on criminal convictions for inmates claimed as qualifying for our 2020 SCAAP submission. This audit has helped us recognize that criminal justice databases housing conviction information are dynamic and ever changing, which makes...

HCSO agrees with the audit finding regarding our lack of documentation on criminal convictions for inmates claimed as qualifying for our 2020 SCAAP submission. This audit has helped us recognize that criminal justice databases housing conviction information are dynamic and ever changing, which makes current verification of historical data very difficult. For this reason it’s very important to maintain detailed documentation of the information used to identify qualifying convictions. For future SCAAP submissions our plan is to take screenshots from the criminal justice databases used to verify convictions and maintain that documentation in files that are routinely backed up. In addition, we will ensure this documentation is reviewed by management to ensure adequacy based on SCAAP requirements.

View Audit 303259 Questioned Costs: $1

Finding 392909 (2023-003)

Significant Deficiency 2023

Rosemont College of the Holy Child Jesus

PA

Questioned Costs Student Financial Aid Significant Deficiency

Going forward, all students who withdrawal from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If it is deemed that f...

Going forward, all students who withdrawal from the College will be forwarded to the financial aid team to review whether a student is still eligible for the full funding of the specific semester in question or whether funding needs to be returned based on the withdrawal date. If it is deemed that funds need to be returned, the Bursar will provide the financial aid team with a copy of the student charges for that period and the Registrar will provide proof of the withdrawal date and the financial aid team will determine the amount of funding that needs to be returned. Financial Aid will then complete the return through the student's account and notify the Controller and VP of Finance and Administration to process the return to G5.

View Audit 303193 Questioned Costs: $1

Finding 392908 (2023-002)

Significant Deficiency 2023

Rosemont College of the Holy Child Jesus

PA

Student Financial Aid Procurement, Suspension & Debarment Allowable Costs / Cost Principles

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic ...

When SAP is run in the spring, students will be notified of their academic standing. Students who are suspended will have an opportunity to appeal their suspension. If the appeal of suspension is approved, students will meet with their academic advisor to be placed on an academic plan. The academic plan must be signed by both the student and advisor. The academic plan must be submitted to the Office of Financial Aid via the teams. A financial aid hold will be placed on the student's account until the signed academic plan is received. Once received, the Office of Financial Aid will remove the hold so the student can be awarded.

View Audit 303193

Finding 392898 (2023-001)

Significant Deficiency 2023

North Providence Housing Authority

RI

HUD Housing Programs Eligibility Significant Deficiency

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing ...

The North Providence Housing Authority will be creating a check list which will include Income Verification as part of the participants file to be used for examinations, and reexaminations of income. This check list will be completed by the Housing Authority staff member, signed, and dated, showing that all required documents have been obtained and used for a successful processing of the tenants rent. Additionally, due to being a small housing authority, with only one HCV staff member, we have hired an HCV Assistant to help the HCV Coordinator in obtaining all information needed to comply with HUD’s regulations. Planned Implementation Date of Corrective Action: January 1, 2024 Planned Implementation Date of Corrective Action: Eileen Reyes/Michael McMahon/ Cheryl Lonardo

View Audit 303175

Finding 392890 (2023-005)

Significant Deficiency 2023

Sioux Falls Housing and Redevelopment Commission

SD

HUD Housing Programs Significant Deficiency Special Tests & Provisions

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Plans are in place to move accounts to another bank. A RFP for a new bank will be released in 2024. Planned Completion Date for CAP June 30, 2024

View Audit 303161

Finding 392883 (2023-004)

Significant Deficiency 2023

Sioux Falls Housing and Redevelopment Commission

SD

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all HQS inspections and abatements are monitored. Staff have been trained on when to properly abate a payment and how to properly document abatements. Pl...

Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all HQS inspections and abatements are monitored. Staff have been trained on when to properly abate a payment and how to properly document abatements. Planned Completion Date for CAP March 1, 2024

View Audit 303161

Finding 392876 (2023-003)

Significant Deficiency 2023

Sioux Falls Housing and Redevelopment Commission

SD

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has implemented a new software program that provides rent reasonableness documentation. Staff have been trained on the proper way to utilize the software and are also now aware of when to run a rent reasonablen...

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has implemented a new software program that provides rent reasonableness documentation. Staff have been trained on the proper way to utilize the software and are also now aware of when to run a rent reasonableness comparison. Planned Completion Date for CAP March 1, 2024

View Audit 303161

Finding 392869 (2023-002)

Significant Deficiency 2023

Sioux Falls Housing and Redevelopment Commission

SD

HUD Housing Programs Eligibility Significant Deficiency

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review ...

Contact Person Brent Tucker, Interim Executive Director Corrective Action Plan Management has begun the process of creating a quality control plan to ensure that all files are accurate and follow all local, state and federal compliance guidelines. An Independent entity has also been hired to review all current files and all corrections have been made. Planned Completion Date for CAP April 30, 2024

View Audit 303161

Finding 392580 (2023-003)

Significant Deficiency 2023

Bristol Bay Area Health Corporation and Subsidiary

AK

Eligibility Significant Deficiency

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages an...

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.

View Audit 302857

Finding 392472 (2023-001)

Significant Deficiency 2023

Sonoran University of Health Sciences

AZ

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding....

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sonoran University will implement the corrective action suggestions outlined in the audit findings, including: • Expansion of vulnerability mitigation to include the prescribed penetration and exploitation operations. • Complete migration of Sonoran servers vendor-supported versions (as of this writing, only two systems remaining). • Implementation of a phishing campaign education initiative for Sonoran University Employees. • Update WISP documents to meet the prescribed documentation requirements. • Build University-consistent data retention strategy. Name of the contact person responsible for corrective action: • Paul Collins, Senior Director of IT, Sonoran University. Planned completion date for corrective action plan: • Completion of all items by September 30, 2024.

View Audit 302771

Finding 392395 (2023-002)

Significant Deficiency 2023

Sicangu Oyate Ho, INC

SD

Reporting Significant Deficiency

Management Response: The School will ensure that the Single Audit reporting package is completed and submitted within the timeline as required by Uniform Guidance. Anticipated Completion Date: March 31, 2025 Responsible Party: Maria Walking Eagle, Business Manager

View Audit 302745

Finding 392365 (2023-001)

Significant Deficiency 2023

Nevins Manor, Inc.

MA

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

Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization obtain approval from HUD to repay the loan advances after the initial due date and to establish internal controls to monitor the repayment of loan advances to e...

Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.157 Recommendation: The Auditors recommend that the Organization obtain approval from HUD to repay the loan advances after the initial due date and to establish internal controls to monitor the repayment of loan advances to ensure compliance with HUD requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procedures have been put in place that all replacement reserve requests due to cash shortfalls are elevated to the VP of Operations who will ensure a plan is in place for timely repayment. Name(s) of the contact person(s) responsible for corrective action: Steve Lodi Planned completion date for corrective action plan: March 21, 2024.

View Audit 302692

Finding 392223 (2023-003)

Significant Deficiency 2023

Concordia University Irvine

CA

Questioned Costs Student Financial Aid Significant Deficiency

Management's Response: Upon discovery of the errors, the University reviewed the population of withdrawn students where the dates for one module were used versus the payment period. The University performed the additional or revised Title IV calculations and returned additional funds. The $3,060 rep...

Management's Response: Upon discovery of the errors, the University reviewed the population of withdrawn students where the dates for one module were used versus the payment period. The University performed the additional or revised Title IV calculations and returned additional funds. The $3,060 reported as questioned costs identified by the auditors has also been returned.

View Audit 302441 Questioned Costs: $1

Finding 392216 (2023-001)

Significant Deficiency 2023

Appalachian Regional Healthcare System, Inc.

GA

Questioned Costs Allowable Costs / Cost Principles Reporting

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guideli...

FINDINGS - FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2023-001 COVID-19 Provider Relief Fund (PRF) – Period 4 Recommendation: • We recommend the System design and implement controls, including levels of review, to ensure qualifying expenses submitted are in accordance with the HHS guidelines with supporting documentation retained. • Action Taken: Management agrees with this finding as stated and the additional actions that will be taken by the System. Management will design controls to establish an adequate review process to ensure consistent and accurate calculations and reconciliations in accordance with HHS guidelines. Rick Cassady, CFO

View Audit 302428 Questioned Costs: $1

Finding 392167 (2023-001)

Material Weakness 2023

Bandon Community Health Center Dba Coast Community Health Center

OR

Special Tests & Provisions Material Weakness Reporting

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all...

2023-001 Special Tests and Provisions - Sliding Fee Discounts Corrective Action Plan Management will create a Procedure for transferring major data systems, such as the EMR, to include transfer of appropriate financial transaction information and/or retention of access to the legacy system until all audit and record retention requirements are met. Anticipated completion date March 31, 2024 Contact person responsible for corrective action Kendra Newbold, Interim CEO

View Audit 302373

Finding 392120 (2023-001)

Significant Deficiency 2023

Adkins Village Non‐profit Housing Corporation

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule ...

March 6, 2024 Adkins Village Non-Profit Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E Grand River Ave, Suite 1 Lansing, Michigan 48912 Audit Period: The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is number consistently with the number assigned in the schedule. Finding - Federal Awards Finding 2023-001 – Significant Deficiency Recommendation: We recommend the Organization put procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. Action to be Taken: The Organization concurs with the facts of this finding and has put procedures

View Audit 302288

Finding 392117 (2023-001)

Significant Deficiency 2023

Tampa Hillsborough Homeless Initiative, Inc.

FL

Subrecipient Monitoring Significant Deficiency

Tampa Hillsborough Homeless Initiative, Inc has established a policy and procedures to review the contract and OMB Compliance Supplement requirements for all Federal and state awards to gain an understanding of the compliance requirements and will have in place internal controls to ensure compliance...

Tampa Hillsborough Homeless Initiative, Inc has established a policy and procedures to review the contract and OMB Compliance Supplement requirements for all Federal and state awards to gain an understanding of the compliance requirements and will have in place internal controls to ensure compliance. The review will be completed by the Chief Executive Officer (Antoinette D. Hayes- Triplett) during the contracting of the award. This will be put into place by March 31, 2024.

View Audit 302285

Finding 392101 (2023-001)

Significant Deficiency 2023

Winslow Unified School District No. 1

AZ

Questioned Costs Cash Management Reporting

FINDINGS—FEDERAL AWARDS 2023-001: Reporting Type of Finding: Noncompliance, significant deficiency Condition/Context: The District overclaimed meals served by 16 lunches, resulting in an overpayment of $71. Action planned in response to finding: The District will evaluate its internal control proced...

FINDINGS—FEDERAL AWARDS 2023-001: Reporting Type of Finding: Noncompliance, significant deficiency Condition/Context: The District overclaimed meals served by 16 lunches, resulting in an overpayment of $71. Action planned in response to finding: The District will evaluate its internal control procedures over the preparation of meal reimbursement claims to eliminate clerical errors to ensure that the meals claimed to the Arizona Department of Education are accurately reported. Planned completion date for corrective action plan: For the period ending June 30, 2024. Name of the contact person responsible for corrective action: Casey Hancock, Business Manager

View Audit 302249 Questioned Costs: $1

Finding 392092 (2023-005)

Significant Deficiency 2023

Housing Authority of Prince George's County

MD

Questioned Costs Special Tests & Provisions Significant Deficiency

Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct...

Recommendation: We recommend the Authority implements controls to ensure that the Authority requires HQS deficiencies to be corrected within the timeframe set forth by 2 CFR section 982.404(a). We recommend the Authority implements controls to ensure abatement is timely for units that do not correct the cited HQS deficiencies within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAPGC will implement policies and procedures and controls to validate landlord and or participant compliance with the timely correction of HQS deficiencies. HAPGC will abate HAP for HQS fails in accordance with the regulations. Name(s) of the contact person(s) responsible for corrective action: Jessica Anderson-Preston Planned completion date for corrective action plan: September 30, 2024.

View Audit 302221 Questioned Costs: $1

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