Corrective Action Plans

Finding 401244 (2022-004)

Significant Deficiency 2022

AL

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline....

Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline. Anticipated completion date: September 30, 2024

View Audit 309234

Finding 401082 (2022-006)

Significant Deficiency 2022

Promise Healthcare Nfp

IL

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.329

Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to deposit all supporting files and schedules in a shared and accessible location: in progress a. Develop steps in the UDS process that outlines where working and final supporting schedules will be stored for future access b. Identify role or job that will handle responsibility for following the procedure. c. Formalize the process into a written procedure and add to the UDS Report or other relevant policy. d. After UDS submission, review data folders to check that all relevant supporting schedules and documents have been deposited.

View Audit 309100

Finding 401079 (2022-004)

Material Weakness 2022

Promise Healthcare Nfp

IL

Questioned Costs Special Tests & Provisions Significant Deficiency

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagre...

Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action

View Audit 309100 Questioned Costs: $1

Finding 401076 (2022-003)

Significant Deficiency 2022

Promise Healthcare Nfp

IL

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection a...

Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: to start 1. Review current policies and procedures: in progress a. Conduct a comprehensive review of existing procedures for collection and verification of patient information to identify weaknesses, gaps, and areas for improvement. b. Conduct review of current front desk workflow to determine if policies and procedures are followed correctly. c. Enhance policies and procedures as necessary to improve accuracy and consistency of patient information 2. Verification Process: to start a. Review documentation requirements for verifying accuracy of sliding fee information and standardize/improve where necessary. 3. Training and Education: to start a. Review training materials and create/improve where necessary to provide clear instructions and comply with policy and procedure b. Train front desk staff on standardized forms, templates and scripts for collecting information from patients c. Require periodic training and re-training to improve front desk workflow and retention of process to consistently collect and verify information from patients 4. Quality Assurance: to start a. Conduct regular audits and quality assurance checks to monitor the accuracy and integrity of sliding fee information and implementation of sliding fee discount b. Implement corrective actions to address any discrepancies or deficiencies identified during audits or reviews Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Summer/Fall 2024

View Audit 309100

Finding 400773 (2022-004)

Significant Deficiency 2022

Great Northwest Education Cooperative

ND

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Contact Person – Ben Schafer, Executive Director Corrective Action Plan – The Executive Director will review and approve, with documentation, all invoices prior to payment being made. Completion Date – The Coop will implement this corrective action plan in the next fiscal year.

View Audit 308791

Finding 400604 (2022-005)

Significant Deficiency 2022

Tca Health, Inc.

IL

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

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort r...

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort reporting policy and model. TCA currently feels that what the process that they utilized to allocate salary and wage expense to the grant related to this finding was allowable from a Uniform Grants Guidance perspective, however they were not compliant with their policy and will work to revise their policy to less restrictive (although still in compliance with the UGG). The iCFO will create greater monitoring of the month-end process as it relates to the allocation of payroll costs to be consistent with the personnel activity reports and the Health Center’s revised policy.

View Audit 308641

Finding 400560 (2022-002)

Significant Deficiency 2022

Kentucky Refugee Ministries, Inc.

KY

Significant Deficiency

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Clearinghouse. Action Taken: KRM has taken steps to increase the staffing in the finance department to help with the increased number of refugees served as well as implementing new software changes to ...

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Clearinghouse. Action Taken: KRM has taken steps to increase the staffing in the finance department to help with the increased number of refugees served as well as implementing new software changes to streamline processes for more efficient operations.

View Audit 308596

Finding 400243 (2022-002)

Significant Deficiency 2022

Housing Authority of the City of Annapolis

MD

HUD Housing Programs Reporting Significant Deficiency § 200.512

Finding 2022-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures and internal controls to ensure the financial reporting package and audited financial statements are submitted by the req...

Finding 2022-002 Late Submission of Financial Statements to FAC and REAC (Significant Deficiency) Recommendation: The Authority should review and enhance its policies, procedures and internal controls to ensure the financial reporting package and audited financial statements are submitted by the required due date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Taken in response to finding: The Authority will evaluate its financial reporting, close processes and controls to determine whether additional controls over the preparation of the final trial balances and related schedules should be implemented. As part of this process, we will create a year end checklist with deadlines established and monitor status to ensure deadlines are met. Name of Contact Person responsible for Corrective Action: Cia Cook, Deputy Executive Director & CFO Planned Date for Corrective Action plan: June 30, 2024

View Audit 308359

Finding 399367 (2022-003)

Significant Deficiency 2022

Eastern Area Workforce Development Board

NM

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.512

Corrective Action: EAWDB agrees that accurate financial statements were not submitted. EAWDB has engaged a third-party accounting firm and made staff duty changes to address the timely submission of accounting information. Due Date of Completion: September 30, 2024. Responsible Party(ies): Operati...

Corrective Action: EAWDB agrees that accurate financial statements were not submitted. EAWDB has engaged a third-party accounting firm and made staff duty changes to address the timely submission of accounting information. Due Date of Completion: September 30, 2024. Responsible Party(ies): Operations Manager, Executive Director

View Audit 307868

Finding 399362 (2022-002)

Significant Deficiency 2022

Los Angeles County - University of Southern California Medical Center Foundation, Inc.

CA

Cash Management Significant Deficiency Internal Control / Segregation of Duties § 200.430

Federal Award Findings and Questioned Costs Finding 2022‐002: Inaccurate Staff Timesheet Support Corrective Action: At monthly staff meetings, we will review current contracts, including terminating contracts and new contracts that are beginning. We will inform and train staff regarding the proper r...

Federal Award Findings and Questioned Costs Finding 2022‐002: Inaccurate Staff Timesheet Support Corrective Action: At monthly staff meetings, we will review current contracts, including terminating contracts and new contracts that are beginning. We will inform and train staff regarding the proper recordkeeping of their time allocation on their timesheets. We will also inform and train managers on more thorough oversight of staff time allocation to contracts as part of the timesheet approval process. Name of Contact Person: Heather Hays, Associate Director Proposed Completion Date: Immediately

View Audit 307844

Finding 398995 (2022-002)

Material Weakness 2022

Municipality of Lajas

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

The Municipality will take all the necessary administrative measures to address and correct this situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultatn and external auditors to meet the deadline for submitting the Single A...

The Municipality will take all the necessary administrative measures to address and correct this situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultatn and external auditors to meet the deadline for submitting the Single Audit Report for the year 2024. Expected completion date: March 30, 2025

View Audit 307603

Finding 398468 (2022-005)

Significant Deficiency 2022

Yuma District Hospital

CO

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In ...

Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In addition, there was lack of review of the quarterly internal monitoring of the Hospital’s debt covenants. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: For the reserve fund reconciliations, a secondary review will be completed and documented. The Hospital will also ensure that the quarterly covenant calculations are completed and presented to the board for review with the financials. Anticipated Completion Date: 05/31/2024

View Audit 307192

Finding 398451 (2022-002)

Significant Deficiency 2022

Brookings County Housing and Redevelopment Commission

SD

Reporting Significant Deficiency § 200.512

CORRECTIVE ACTION PLAN (Unaudited), continued YEAR ENDED DECEMBER 31, 2022 The Brookings County Housing and Redevelopment Commission respectfully submits the following corrective action plan for audit findings for the year ended December 31, 2022. Independent Public Accounting Firm: Wohlenberg, R...

CORRECTIVE ACTION PLAN (Unaudited), continued YEAR ENDED DECEMBER 31, 2022 The Brookings County Housing and Redevelopment Commission respectfully submits the following corrective action plan for audit findings for the year ended December 31, 2022. Independent Public Accounting Firm: Wohlenberg, Ritzman and Co. LLC P.O. Box 1018 Yankton, SD 57078 Audit Period: January 1, 2022 - December 31, 2022 The findings from the December 31, 2022 Schedule of Findings and Questioned Costs are discussed below. Findings Related to Major Federal Award Program Finding 2022-002 Reporting (Compliance; Internal Control Over Compliance) Condition as Noted in Auditor’s Finding: The Commission did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of September 30, 2023. Responsible Individuals: Board of Commissioners and Management Correction Action Plan: The Commission will implement procedures to begin audit preparation work earlier in the calendar year to ensure reports are filed within the nine-month reporting deadline set forth by Uniform Guidance. Anticipated Complete Date: September 30, 2024 Very truly yours, BROOKINGS COUNTY HOUSING AND REDEVELOPMENT COMMISSION Rich Galbraith Executive Director

View Audit 307132

Finding 398354 (2022-003)

Significant Deficiency 2022

Eastern Plains Community Action Agency, Inc.

NM

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency

Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be rev...

Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be reviewed to ensure the appropriate approvals and signatures are obtained. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 307024

Finding 398353 (2022-002)

Significant Deficiency 2022

Eastern Plains Community Action Agency, Inc.

NM

Equipment & Real Property Management Internal Control / Segregation of Duties Reporting § 200.303

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective du...

Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective due dates. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023

View Audit 307024

Finding 398254 (2022-004)

Significant Deficiency 2022

City of Dunkirk Housing Authority

NY

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

2022-004 Significant Deficiency: See finding 2022-004. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Action taken: We concur with t...

2022-004 Significant Deficiency: See finding 2022-004. Federal program: Public Housing Capital Fund CFDA 14.872 Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Action taken: We concur with the recommendation. The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its budget was not prepare by AMP location. Management engaged the services of a fee-accountant subsequent to year-end who will assist with the budgeting process starting in the 2024-2025 fiscal year.

View Audit 306946

Finding 398252 (2022-002)

Significant Deficiency 2022

City of Dunkirk Housing Authority

NY

HUD Housing Programs Significant Deficiency

2022-002 Significant Deficiency: See finding 2022-002. Federal program: Special Needs Assistance Program-CFDA 14.238 Recommendation: We recommend that management of the Authority review its processes for closing out all fullyexpended grants with HUD to ensure that, in the future, when grants are...

2022-002 Significant Deficiency: See finding 2022-002. Federal program: Special Needs Assistance Program-CFDA 14.238 Recommendation: We recommend that management of the Authority review its processes for closing out all fullyexpended grants with HUD to ensure that, in the future, when grants are fully expended, the close-out process begins shortly thereafter. Action taken: We concur with the recommendation. The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that several older grants were still shown as "open" and that the close-out procedures would have to be implemented at some point. Management is evaluating its process and procedures related to closing out grants and is planning on implementing procedures to ensure grants are properly closed.

View Audit 306946

Finding 398249 (2022-001)

Significant Deficiency 2022

Assemblies of God Family Services Agency

AR

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Former finance manager had been replaced by the time the audit began. Interim finance manager, Stephanie Polites wrote off all uncollectable or undocumented accounts receivable, and implemented a new tracking and monitoring system to be reviewed on a periodic basis. No issues noted since implementat...

Former finance manager had been replaced by the time the audit began. Interim finance manager, Stephanie Polites wrote off all uncollectable or undocumented accounts receivable, and implemented a new tracking and monitoring system to be reviewed on a periodic basis. No issues noted since implementation.

View Audit 306926

Finding 398193 (2022-002)

Significant Deficiency 2022

East Alabama Regional Planning and Development Commission

FL

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finance Department was and is undergoing software conversion that has presented a large learning curve to finance staff. EARPDC will endeavor to complete audit filing on time in 2023.

View Audit 306900

Finding 398102 (2022-002)

Material Weakness 2022

East Side Neighborhood Services, Inc.

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining our assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the completed stateme...

Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining our assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the completed statements and distributes them to the users.

View Audit 306840

Finding 397018 (2022-003)

Significant Deficiency 2022

Mobile Housing Authority

AL

Eligibility HUD Housing Programs Significant Deficiency

MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Hous...

MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that crosschecks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Housing Specialist-II team lead to oversee staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. MHA also implemented two compliance analysts in 2023; these staff persons currently report to the Program Management Analyst who monitors HUD’s PIC system and analyzes discrepancies between PIC data and MHA data housed in the Yardi system of record. This information is maintained in the program file. Responsible Person: Magdalene Watkins, Program Administrator Projected Completion Date: April 30, 2024

View Audit 306404

Finding 397016 (2022-002)

Significant Deficiency 2022

Mobile Housing Authority

AL

HUD Housing Programs Internal Control / Segregation of Duties Reporting

Management has reviewed its staffing needs and end of year complexities and requirements necessary to report U.S. GAAP basis financial statements. Management has hired additional staff that possess the necessary accounting and reporting skills and experience to assist with interim reporting, end of ...

Management has reviewed its staffing needs and end of year complexities and requirements necessary to report U.S. GAAP basis financial statements. Management has hired additional staff that possess the necessary accounting and reporting skills and experience to assist with interim reporting, end of year close, reconciliations of all significant account balances, and strengthening the internal controls over financial reporting including amounts reported in the financial data schedule. In addition to these action steps, we will get started earlier in conducting our end of year reconciliations and enhance our over-sight so we can better monitor and evaluate our readiness to report our financial statements in compliance with 24 CFR Section 5.801. Responsible Person: Jeffery J. Bennett, Chief Financial Officer Projected Completion Date: June 30, 2023

View Audit 306404

Finding 396508 (2022-002)

Significant Deficiency 2022

Mental Health Association in Orange County, Inc.

NY

Special Tests & Provisions HUD Housing Programs Significant Deficiency

• Finding 2022-002 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions: o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: The agency has developed, revised and implem...

• Finding 2022-002 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions: o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: The agency has developed, revised and implemented internal controls in the form of written program policies and procedures to ensure that the agency is in compliance with changes to regulatory requirements. Worksheets are now updated annually and verified by the Director of Corporate Compliance to reflect the current utility allowances within 30-days of publication. The Assistant Director of Housing and Care Coordination will notify all staff responsible for administering HUD programs of the policy changes and train those staff accordingly. o Person Responsible: John Lent, Director of Corporate Compliance o Date of Completion: July 31, 2024

View Audit 306118

Finding 396507 (2022-001)

Significant Deficiency 2022

Mental Health Association in Orange County, Inc.

NY

Special Tests & Provisions HUD Housing Programs Significant Deficiency

• Finding 2022-001 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: The agency has developed, revised and impleme...

• Finding 2022-001 – Compliance and Significant Deficiency in Internal Control over compliance with Special Tests and Provisions o U.S. Department of Housing and Urban Development o Agency Response: Concurs with audit findings. o Corrective Action Plan: The agency has developed, revised and implemented internal controls in the form of written program policies and procedures to ensure that the agency is in compliance with changes to regulatory requirements. Worksheets are now updated annually and verified by the Director of Corporate Compliance to reflect the current fair market rent tables within 30-days of publication. The Assistant Director of Housing and Care Coordination will notify all staff responsible for administering HUD programs of the policy changes and train those staff accordingly. o Person Responsible: John Lent, Director of Corporate Compliance o Date of Completion: July 31, 2024

View Audit 306118

Finding 396193 (2022-001)

Significant Deficiency 2022

Butte Local Development Corporation

MT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Butte Local Development Corporation's fiscal year end is October31. By mid-december, a draft of the Annual Financiel Statements will be prepared by fiscal staff and made available to review by the Executive Director and Board of Directors. Final financial statements will be sent to the auditor by mi...

Butte Local Development Corporation's fiscal year end is October31. By mid-december, a draft of the Annual Financiel Statements will be prepared by fiscal staff and made available to review by the Executive Director and Board of Directors. Final financial statements will be sent to the auditor by mid-January to allow ample time to conduct the audit and submit the audit to the Federal Audit Clearinghouse before the due date

View Audit 305818

Corrective Action Plans

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