Corrective Action Plans

Finding 573814 (2022-005)

Significant Deficiency 2022

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 364481

Finding 573379 (2022-003)

Significant Deficiency 2022

Kama'aina Care, Inc.

HI

Questioned Costs Subrecipient Monitoring Reporting

Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.

View Audit 364154

Finding 573220 (2022-002)

Significant Deficiency 2022

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

Managements Corrective Action Plan Year Ending – December 31, 2022 Schedule of finding and Questioned Costs: Section II – Financial Statement Findings: 2022-001 – Internal Control over Patient Accounts Receivable Financial Close and Reporting Section III – Federal Award Findings: 2022-002 - Reportin...

Managements Corrective Action Plan Year Ending – December 31, 2022 Schedule of finding and Questioned Costs: Section II – Financial Statement Findings: 2022-001 – Internal Control over Patient Accounts Receivable Financial Close and Reporting Section III – Federal Award Findings: 2022-002 - Reporting ALN #93.217 Contact: Jennifer Moore Title: Controller Completion Date – September 2024 Corrective Action – Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings:  We have redefined the allowance calculation methodology, relying on historical analysis and improved reporting that more accurately determines the doubtful receivables.  In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process.

View Audit 364043

Finding 571394 (2022-004)

Significant Deficiency 2022

Lake Health District

OR

Special Tests & Provisions Questioned Costs Subrecipient Monitoring § 200.303

Management is aware of deposit requirements and has committed the resources to ensure minimum deposit requirements are met.

View Audit 362331

Finding 571393 (2022-003)

Significant Deficiency 2022

Lake Health District

OR

Matching / Level of Effort / Earmarking Questioned Costs Reporting § 200.512

Management is aware of reporting requirements and has committed the resources to ensure timely filing for future reports.

View Audit 362331

Finding 571312 (2022-001)

Significant Deficiency 2022

North Central Alabama Regional Council of Local Governments

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

FINDINGS- FINANCIAL STATEMENT AUDIT SIGNFICANT DEFICIENCY Finding 2022-001 - Reporting : The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Audit Finding 2022-001 : Background: In March of 2022...

FINDINGS- FINANCIAL STATEMENT AUDIT SIGNFICANT DEFICIENCY Finding 2022-001 - Reporting : The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Audit Finding 2022-001 : Background: In March of 2022 , NARCOG had a transition of leadership in the Finance Department. The new Finance Director had to be set up as an authorized representative for the organization before reporting could be submitted, which caused a delay in reporting in a timely manner. The Finance Director is still learning the process and requirements of the financial data for the reporting. Conclusion: Going forward NARCOG will have a three-member team to ensure that reporting is submitted in a timely manner. The Finance Director, Executive Director, and Planning Director will all have the capability of completing and submitting reports.

View Audit 362261

Finding 570879 (2022-004)

Significant Deficiency 2022

Homeless Resource Council of the Sierras

CA

Subrecipient Monitoring Significant Deficiency

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

View Audit 361819

Finding 570876 (2022-001)

Significant Deficiency 2022

Homeless Resource Council of the Sierras

CA

Questioned Costs Reporting Significant Deficiency § 200.512

We agree with this finding and are in the process of preparing for and completing the June 30, 2023 and June 30, 2024 audits. We plan to have the June 30, 2024 single audit filed by the deadline date.

View Audit 361819

Finding 570778 (2022-007)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Questioned Costs § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721

Finding 570739 (2022-003)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721 Questioned Costs: $1

Finding 570734 (2022-002)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Cash Management Questioned Costs Material Weakness § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721

Finding 570503 (2022-003)

Significant Deficiency 2022

City of Princeton

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.328

FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting ...

FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Significant Deficiency Condition: The City did not have proper controls in place to ensure that the annual report was accurately filled out and agreed to underlying detail. Context: Variances to key line items were noted when comparing the Form RD442-2 and Form RD442-3 to supporting documents. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that reports agree to underlying detail. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

View Audit 361490

Finding 570502 (2022-002)

Significant Deficiency 2022

City of Princeton

IN

Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.313

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compli...

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compliance Requirements: Equipment and Real Property Management Audit Findings: Significant Deficiency Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The City did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the capital asset listing is maintained throughout the year and CIP is tracked. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

View Audit 361490

Finding 570479 (2022-001)

Significant Deficiency 2022

Clean Fuels Ohio

OH

Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its intern...

Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its internal control policies for payroll transaction cycle, which includes a review of all hours and rates by supervisors and the Executive Director. This occurs prior to the submission of payroll data to the Organization’s third-party payroll processor. An additional control procedure includes the review of changes made to the payroll system regarding new employees and any changes to pay rates.

View Audit 361433

Finding 565073 (2022-001)

Significant Deficiency 2022

United Way of Marion County, Inc.

FL

Cash Management Reporting Significant Deficiency

The individual random client sample of 60 participants did not detect any duplications. However, as a new administrator we became aware of the duplicates as identified in the reconciliation provided to the auditors. The manual process used contributed to the duplications in ERA1 and ERA2. The duplic...

The individual random client sample of 60 participants did not detect any duplications. However, as a new administrator we became aware of the duplicates as identified in the reconciliation provided to the auditors. The manual process used contributed to the duplications in ERA1 and ERA2. The duplications do not appear to be more than the allowable limits. If United Way of Marion County, Inc. would take on such a large endeavor in the future the organization would invest in a digital system. As the new President & CEO, I did my own sampling from the paper applications and payments for examination and gain knowledge of how system change would provide improved internal controls.

View Audit 359012

Finding 563972 (2022-008)

Significant Deficiency 2022

Bach Viet

CA

Significant Deficiency Internal Control / Segregation of Duties

Management’s Planned Corrective Action: It is the policy of the Association that all timesheets must be signed by the employee and the employee’s supervisor. At the present time all time sheets are given to me for review and approval. It is my responsibility to verify that the time sheets have the p...

Management’s Planned Corrective Action: It is the policy of the Association that all timesheets must be signed by the employee and the employee’s supervisor. At the present time all time sheets are given to me for review and approval. It is my responsibility to verify that the time sheets have the proper signatures on them before I give them to the bookkeeper for processing. I can only assume that the transactions that you reviewed were not complete due to the fact that timesheets were not signed due to the fact that some employees were not in the office due to Corvid. Responsible Party: Mel Demoff, Executive Director Completion Date: December 31, 2023

View Audit 358145

Finding 563971 (2022-007)

Significant Deficiency 2022

Bach Viet

CA

Questioned Costs Allowable Costs / Cost Principles Cash Management

Management’s Planned Corrective Action: I am in the process of working with our CPA in implementing a Cost Allocation plan that will accurately allocate costs between all programs and these costs will be developing a system whereby the monthly reports will be based on number served rather than the n...

Management’s Planned Corrective Action: I am in the process of working with our CPA in implementing a Cost Allocation plan that will accurately allocate costs between all programs and these costs will be developing a system whereby the monthly reports will be based on number served rather than the number of participants. Responsible Party: Mel Demoff, Executive Director Completion Date: January 1, 2024

View Audit 358145

Finding 563946 (2022-005)

Significant Deficiency 2022

Neighborhood Medical Center, Inc.

FL

Questioned Costs Reporting Significant Deficiency § 200.303 § 200.512

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 shortages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 audit will be completed by August 31, 202...

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 shortages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 audit will be completed by August 31, 2025. Engagement contracts have been issued for the 2023 and 2024 audits.

View Audit 358122

Finding 561172 (2022-002)

Significant Deficiency 2022

Native Village of Nunapitchuk

AK

Reporting Significant Deficiency § 200.512

Finding 2022-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Eli Wassillie, Tribal Administrator Corrective Action Plan: Management will engage a CPA firm with enough advanced timing to ensure that the single audit is completed and submitted within the 9-month ti...

Finding 2022-002 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Eli Wassillie, Tribal Administrator Corrective Action Plan: Management will engage a CPA firm with enough advanced timing to ensure that the single audit is completed and submitted within the 9-month time period. Proposed Completion Date: December 31, 2024.

View Audit 356763

Finding 561169 (2022-001)

Significant Deficiency 2022

M. Carter Plaza

OR

HUD Housing Programs Allowable Costs / Cost Principles Reporting § 200.512

Finding no.: 2022-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to the fiscal manager position at PCRI experiencing turnover in September of 2019, this, along with the onset of COVID-19 in the first quarter of 2020 led ...

Finding no.: 2022-001 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: The late filing was due to the fiscal manager position at PCRI experiencing turnover in September of 2019, this, along with the onset of COVID-19 in the first quarter of 2020 led to delays in the normal review and submission of the data collection form. The fiscal manager position has been staffed and is aware of the deadline related to the submission of the data collection form. Anticipated completion date: October 2023

View Audit 356760

Finding 561167 (2022-002)

Significant Deficiency 2022

Portland Community Reinvestment Initiatives, Inc.

OR

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.512

Finding no.: 2022-002 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: As has been addressed earlier in management’s response to Finding 2022-001, PCRI had created and filled two new positions in the Fiscal Department — the Controller and an additional...

Finding no.: 2022-002 Contact person(s) responsible: Kymberly Horner, Executive Director Corrective action planned: As has been addressed earlier in management’s response to Finding 2022-001, PCRI had created and filled two new positions in the Fiscal Department — the Controller and an additional Staff Accountant. The additional staff led to better internal controls and more timely reconciliations throughout 2022. Notwithstanding these efforts, time was needed to train personnel on PCRI systems and emphasis was put on the completion of the subsidiary audits for King Parks Apartments Limited Partnership and MLK & Cook Apartments Limited Partnerships, which are an integral part of the consolidated PCRI audit report, in the early months of 2022 leading to the noted delay in reconciliations for the PCRI audit. In addition to these delays, PCRI once again experienced turnover in the added Staff Accountant position in June of 2023, leading to delays and the employee in the Controller position went on an extended medical leave and subsequently ended employment with PCRI, leading to further delays. Further contributing to delays was the turnover of accounting staff at the property management company with whom PCRI contracts for management of the Maya Angelou and Park Terrace properties which lead to delays in starting those audit engagements which are integral to the consolidated PCRI audit report. In response to this cycle of staff turnover, PCRI contracted with an external service to fill the Staff Accountant position while the search for a permanent employee to fill the position continues to this day, and PCRI has subsequently hired a well-qualified person as Fiscal Director. The property manager for the Maya Angelou and Park Terrace properties has also taken steps to stabilize their accounting operations. These responses have mitigated the risk of delay of future audits as the additional personnel hired in response to the 2021 finding was effective were it not for the untimely turnover of staff during the time when the 2022 PCRI audit was being prepared for and conducted. Anticipated completion date: December 2023

View Audit 356759

Finding 560096 (2022-002)

Significant Deficiency 2022

Central Area Rural Transit System, Inc.

AK

Questioned Costs Reporting Significant Deficiency § 200.512

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan To prevent recurrence of the late filing of financial reports, staff will work to prepare year end reconciliations for major programs, state and federal schedules of expendit...

Finding 2022-002 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Corrective Action Plan To prevent recurrence of the late filing of financial reports, staff will work to prepare year end reconciliations for major programs, state and federal schedules of expenditures to determine single audit status, and file corresponding reports in a timely manner. Expected Completion Date June 30, 2025

View Audit 356073

Finding 560043 (2022-001)

Significant Deficiency 2022

Wisconsin Cheese Makers Association

WI

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of th...

Comments on findings and recommendations Management should implement a process to evaluate and allocate expenses on a regular basis. Actions taken or planned Management implemented a process to evaluate and allocate expenses based on employee estimates of time spent by function and proportion of the association’s floor space utilized by each employee during the year. Anticipated completion date July 1, 2023

View Audit 355971

Finding 559805 (2022-008)

Significant Deficiency 2022

Redevelopment Authority of the County of Berks

PA

Reporting Questioned Costs Significant Deficiency § 200.510

PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Emergency Rental A...

PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The Authority provided information relating to the federal programs including grant agreements and other supporting documentation. However, the information prepared by the auditee required material adjustments as a result of audit procedures. Certain account reconciliations were not performed prior to the audit, which impacted amounts reported on the SEFA. Recommendation In order to meet Uniform Guidance requirements, the Authority should prepare the SEFA from the grant award documentation and any other relevant information including the assistance listing numbers, grant award amounts, grant amounts received, grant amounts expended, and grant revenue recorded. The amounts reported in the SEFA should reconcile to the general ledger. Management Response The Authority researched the method to prepare a SEFA and will be preparing the SEFA starting with the 2023 audit.

View Audit 355767

Finding 559798 (2022-006)

Significant Deficiency 2022

Redevelopment Authority of the County of Berks

PA

Questioned Costs HUD Housing Programs Reporting

REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The Authority did not maintain documentation of internal ...

REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The Authority did not maintain documentation of internal controls over reporting for the programs. For required Community Development Block Grant Reporting under Section 3 of the Housing and Urban Development Act of 1968, total Labor Hours reported for 2022 did not agree to support maintained. Additionally, for the Emergency Rental Assistance program, while reporting spreadsheets were provided, supporting documentation for the amounts reported were not maintained. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review their recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response The Authority contracted with Neighborly Software for a program to use with ERAP. At the beginning of ERAP, the Authority relied upon the data from the Neighborly program to generate its reports. By the 4th quarter of 2021, the Authority realized it could only utilize a portion of the Neighborly program for the data required for the reports and needed to supplement or add its own internal data. This method of utilizing Neighborly and internal data is now being used for reports.

View Audit 355767

Corrective Action Plans

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