Corrective Action Plans

Finding 31315 (2022-001)

Significant Deficiency 2022

IL

Procurement, Suspension & Debarment Significant Deficiency

Action taken in response to finding: Procedures are in place, but due to changes in purchasing personnel, the process to verify entities during the fiscal year were not operating effectively. The College will formalize and ensure the consistent operation of a vendor verification process for its cove...

Action taken in response to finding: Procedures are in place, but due to changes in purchasing personnel, the process to verify entities during the fiscal year were not operating effectively. The College will formalize and ensure the consistent operation of a vendor verification process for its covered transactions.

View Audit 30744

Finding 31267 (2022-004)

Significant Deficiency 2022

Ravenwood Mental Health Center, INC

OH

Questioned Costs Cash Management Significant Deficiency § 200.516

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made...

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made changes in the accounting department during the past year to improve the overall functionality. Since we tripled our amount of grants, it was necessary to increase the accounting staff to maintain them, as well as increase overall efficiencies. We now have a staff of 4 accountants, as well as a new CFO with nonprofit/grant experience. The late filling of vacant positions delayed some of our internal processes during their training. We added monthly meetings with internal staff to make sure we have a good communication flow and appropriate documentation for new and existing grants which are monitored monthly Anticipated Completion Date: June 30, 2023

View Audit 31455 Questioned Costs: $1

Finding 31264 (2022-003)

Significant Deficiency 2022

Stockton Port District

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficien...

Finding 2022-003 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Reporting Type of Finding: Significant Deficiency, Instance of Non-compliance Views of Responsible Officials: We concur. Corrective Action Plan: Update reporting procedures to include documentation of the individual that prepared the semi-annual performance reports Responsible Individual(s): Steve Larson, Grants Manager Jeff Wingfield, Deputy Port Director, Regulatory & Public Affairs Anticipated Completion Date: Procedures to be updated by March 31, 2023.

View Audit 30245

Finding 31263 (2022-002)

Significant Deficiency 2022

Stockton Port District

CA

Procurement, Suspension & Debarment Significant Deficiency § 200.327

Finding 2022-002 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Procurement, Suspension and Debarment Type of F...

Finding 2022-002 Federal Agency: U.S. Department of Homeland Security Federal Financial Assistance Listing: 97.056 Applicable Federal Award Number: EMW-2019-PU-00447 & EMW-2020-PU-00288 Program Name: Port Security Grants Program Compliance Requirement: Procurement, Suspension and Debarment Type of Finding: Significant Deficiency, Instance of Non-compliance Views of Responsible Officials: We concur. Corrective Action Plan: Review and update the District?s Procurement procedures to ensure that all required provisions are included in its contracts. Responsible Individual(s): Juan Villanueva, Director of Facilities and Procurement Anticipated Completion Date: Initial update to procurement procedures to be completed by March 31, 2023 with periodic reviews.

View Audit 30245

Finding 31249 (2022-003)

Significant Deficiency 2022

Newbury Elderly Housing, Inc.

NH

Allowable Costs / Cost Principles Reporting Significant Deficiency

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing st...

Finding 2022-003: Plan: Shortages in staffing resulted in incomplete implementation of con-ective action plan in 2021. Documentation and differentiation of job duties for Director of Housing and Project Manager will continue to be developed and implemented. Documentation of non-site-based housing staff members allocation of time to a prope1iy will continue to be implemented and refined. Anticipated Completion: December 31, 2022 ( ongoing) Contact: Jill Lesmerises, Chief Fiscal Officer Michael Tabory, Chief Operating Officer

View Audit 26553

Finding 31233 (2022-001)

Significant Deficiency 2022

Valley Crossroads, Inc.

UT

HUD Housing Programs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

1. Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding. b. Action(s) Taken or Planned on the Finding The Corporation will take the following steps: (1) Develop a plan to address staffing and turnover issues: we will work with the HR department to d...

1. Finding 2022-001 a. Comments on the Finding and Each Recommendation: Management agrees with the finding. b. Action(s) Taken or Planned on the Finding The Corporation will take the following steps: (1) Develop a plan to address staffing and turnover issues: we will work with the HR department to develop a plan to address staffing and turnover issues. This may include conducting a salary and benefits review to ensure that we are competitive in the market, providing opportunities for professional development and growth, and creating a positive work environment; (2) Prioritize the completion of annual recertifications: we will work with the team to prioritize the completion of annual recertifications. This will involve allocating additional resources, if necessary, and bringing in outside help to complete the recertifications on time; (3) Develop a monitoring plan: we will develop a monitoring plan to ensure that annual reexaminations are completed on time. This will include regular checks of tenant files and random sampling to ensure compliance with the regulations; (4) Train staff: we will ensure that all staff involved in the annual reexamination process are trained on the importance of completing them on time, the potential consequences of failing to do so, and the regulations and policies related to annual reexaminations; and (5) Implement a tracking system: we will implement a tracking system to ensure that annual reexaminations are completed on time. The system will include reminders for staff and tenants and a process for tracking the progress of each recertification.

View Audit 36537

Finding 31232 (2022-002)

Significant Deficiency 2022

Central Peninsula General Hospital, Inc.

AK

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

Finding 2022-002: Allowable Costs- Noncompliance and Significant Deficiency in Internal Control over Compliance. Program : Emergency Grants to Address Mental and Substance Use Disorders During Covid -19, Assistance Listing Number: 93.665. Planned Corrective Action Plan : To eliminate human error...

Finding 2022-002: Allowable Costs- Noncompliance and Significant Deficiency in Internal Control over Compliance. Program : Emergency Grants to Address Mental and Substance Use Disorders During Covid -19, Assistance Listing Number: 93.665. Planned Corrective Action Plan : To eliminate human error due to manual keying, we are now running a canned report out of the payroll system which displays employee name, employee number, and current pay rate in an Excel file . This report is emailed to the Behavioral Health supervisor who prepares the payroll portion for each grant. Completion Date : Already implemented. Contact: Nicki McKinney, Controller (nmckinney@cpgh .org)

View Audit 34916

Finding 31209 (2022-001)

Significant Deficiency 2022

Puerto Rico Department of Justice

PR

Allowable Costs / Cost Principles Reporting Significant Deficiency

Below we break down the Action Plan to address finding 2022-001. We must begin our comments by informing that, on December 28, 2022, the PRDOJ formalized a professional services contract number 2023-000067 with the company Aquino, De Cordova, Alfaro & Co., LLP (Independent Auditors) to carry out th...

Below we break down the Action Plan to address finding 2022-001. We must begin our comments by informing that, on December 28, 2022, the PRDOJ formalized a professional services contract number 2023-000067 with the company Aquino, De Cordova, Alfaro & Co., LLP (Independent Auditors) to carry out the Agency financial audit process for fiscal year 2021-2022. The clause number six of the contract required that the Independent Auditors submitted on or before March 31, 2023, the final Single Audit Report required as part of the audit process. However, the PRDOJ was obliged to extend the term of the contract because the Independent Auditors could not complete the contracted services and render the Single Audit Report within the stipulated term. The Independent Auditors indicated that the delay in the delivery of the Single Audit Report was since the audit process could not be started until the contract was signed and that the information was not received in a timely manner. Despite the reasons stated by the Independent Auditors, the reality is that the Independent Auditors undertook the contractual clauses agreed in the contract and between them, the agreement to submit the final Single Audit on or before March 31, 2023. Pursuant to the provisions of contract number 2023-000067, the administration of the PRDOJ was under the understanding that the Independent Auditors would comply with the delivery term of the SingleAudit Report within the agreed term. In this way, we ensured that we hired a firm that complied with the term to submit the Single Audit Report to the Federal Audit Clearinghouse provided in federal statute 45 CFR sec. 75.512. However, it is not until the end of the month of March that we become aware that the Independent Auditors could not meet the deadline of submitting the Single Audit Report. As a result of this, the PRDOJ had to extend the contract so that the Independent Auditors could complete the Single Audit Report, take internal measures to alleviate and address the delay, and submit the PRDOJ's Single Audit Report for fiscal year 2021 to the Federal Audit Clearinghouse. Under the contextual framework outlined above, we inform our corrective action plan to finding number 2022-01 presented in the Single Audit Report. First, the PRDOJ requested in June several proposals from Independent Auditors to carry out the Agency?s financial audit process for the 2022-2023 fiscal year. Consequently, a firm of Independent Auditors was selected, and we requested all the information and documentation required at the federal and state level to contract with the government. The contract was drafted in July and will soon be signed. In addition, the new contract provides that the Independent Auditor must submit the Single Audit Report to the PRDOJ on or before March 1, 2024. In this way, the PRDOJ will have the Single Audit Report in advance and, in this way, ensure that the document is submitted before March 31, 2024, to the Federal Audit Clearinghouse.This initiative goes hand in hand with the elaboration of a rigorous and meticulous work plan between the PRDOJ and the Independent Auditors with the delivery dates and exchange of information for the preparation of the Single Audit Report. The work plan provides that the audit process will begin as soon as the contract is signed in early August. For its part, the PRDOJ must submit all the required information to the Independent Auditors before the end of December. ? Regarding the internal administrative aspects of the PRDOJ to comply with this corrective action plan, we inform that we have designated an employee of the Agency to ensure that all our dependencies and their directors submit all the information required to the Independent Auditors on time on the stipulated dates. This includes, but is not limited to, all information in the preliminary PBC and any additional information that is required by the Independent Auditors. ? Likewise, this PRDOJ employee will serve as a link between the firm of Independent Auditors and the agencies of the agency that request information and documentation. Lastly, the PRDOJ official will ensure that the Independent Auditors firm submits the Single Audit Report to the Federal Audit Clearinghouse before March 31, 2024.This is a comprehensive corrective action plan that we have prepared in coordination with all the dependencies of the PRDOJ to guarantee faithful compliance with federal statutes.

View Audit 31223

Finding 31197 (2022-004)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Finding 2022 ? 004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO ? 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO ? 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Special Tests and Provisions ? Reasonable Rent Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Condition: The Authority did not perform rent reasonableness procedures in accordance with program compliance requirements. Exceptions noted in 2 out of 80 files tested for reasonable rent requirements: Documentation for the determination of rent was not maintained for 1 sample. The contract rent did not agree to the rent determined reasonable for 1 sample. Cause: The Authority did not maintain documentation utilized to determine rent reasonableness. Auditors Recommendation: Recommend that the Authority implements controls to ensure that documentation is maintained in accordance with rent reasonableness requirements. Response to Finding 2022-004 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 80 files tested for reasonable rent requirements. Exceptions were noted in two instances, documentation for the determination of rent was not maintained for 1 sample; and the contract rent did not agree to the rent determined reasonable for 1 sample. Action Taken: A Corrective Action Plan has been developed to ensure that documentation is maintained in accordance with rent reasonableness requirements. Implementation began on August 1, 2023. To provide consistency, increase staff knowledge and reduce errors, training will be held immediately and then annually thereafter. In addition, HAKC will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. Quality reviews will be conducted for all files to ensure that all required documents are in the files. It is anticipated it will take one year to complete the initial file review. After the initial review files will be selected randomly and reviewed according to an established quality control schedule. Each team member will be responsible to collect missing documents identified when completing an annual recertification, interim recertification or change of unit. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director Planned completion date for corrective action plan: March 1, 2024.

View Audit 28025

Finding 31196 (2022-003)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Finding 2022 ? 003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Special Tests and Provisions ? Housing Assistance Payment (HAP) Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters- Condition: The Authority did not ensure the monthly HAP payment agreed between the HUD- 50058, HAP contract, and HAP register in accordance with program compliance requirements. Exceptions were noted in 2 out of 40 files tested for Housing Assistance Payments. In both instances, the HAP register did not agree to the HUD-50058 and HAP contract. Cause: The Authority did not identify variances between the HUD-50058, HAP contract, and HAP register. Auditors Recommendation: Recommend that the Authority implements controls to ensure the HAP paid agrees to the HUD-50058 and HAP contract. Response to Finding 2022-003 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 40 files tested for Housing Assistance Payments. In two instances, the HAP register did not agree to the HUD-50058 and HAP contract. Action Taken: A Corrective Action Plan has been developed to ensure the HAP register agrees with the HUD 50058 and HAP contract. Implementation began on August 1, 2023. To provide consistency for the HUD 50058 HAKC will increase staff knowledge and reduce errors through training. This will be held immediately and then annually thereafter. In addition, we will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. In regard to the HAP contract, going forward any new HAP contracts will be reviewed by the supervisor of the department before the HAP is enforced. The supervisor will sign the HAP contract if no errors are found. With this quality control in effect, the HAP contract will match the HAP register. Quality reviews will also be conducted by compliance to check the HAP contracts to make sure they comply. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director Planned completion date for corrective action plan: March 1, 2024.

View Audit 28025

Finding 31195 (2022-002)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

HUD Housing Programs Reporting Significant Deficiency

Finding 2022 ? 002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Reporting ? PIH Information Center (PIC) Reporting Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Condition: The Authority did not satisfy PIC reporting requirements in accordance with 24 CFR Part 908. Exceptions were noted in 4 out of 40 recertifications. In each of the four instances, the HUD-50058 was unable to be located within the PIC system. Cause: The Authority did not identify recertifications that failed to upload to the PIC system. Auditor?s Recommendations: Recommend that the Authority implement controls to ensure HUD-50058 recertifications are uploaded to PIC. Response to Finding 2022-002 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 40 Recertifications and identified four instances where the HUD- 50058 was not located within the PIC system. Action Taken: A Corrective Action Plan has been developed to ensure HUD-50058 recertifications are uploaded to PIC. Implementation began on August 1, 2023. To provide consistency, the plan is to upload the HUD-50058 sixty days in advance of the recertification date. HAKC will upload the HUD-50058 every week to ensure recertifications are registered in PIC. In addition, we will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director. Planned completion date for corrective action plan: March 1, 2024.

View Audit 28025

Finding 31194 (2022-001)

Significant Deficiency 2022

Housing Authority of Kansas City, Missouri

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Finding 2022 ? 001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Require...

Finding 2022 ? 001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Housing Voucher Cluster Assistance Listing Number: 14.871/14.879 Federal Award Identification Number and Year: MO002VO - 2022 Award Period: January 1, 2022 ? December 31, 2022 Compliance Requirement: Eligibility Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Condition: Exceptions noted in 1 out of 40 files tested for eligibility requirements. The Authority was unable to provide documentation for releases of information or third-party verification of reported family annual income, the value of assets, or expenses related to deductions from annual income. Cause: The Authority did not maintain supporting documentation within the tenant file. Auditor?s Recommendations: Recommend that the Authority implements controls to ensure the tenant files include all required documentation at the time of recertification. Response to Finding 2022-001 The Authority generally concurs with the auditor?s findings and recommendations. The 2022 Audit included the review of 40 HCV files and deficiencies were noted in only one file. The Authority was unable to provide documentation for releases of information or third-party verification of reported family annual income, the value of assets, or expenses related to deductions from annual income. Action Taken: The implementation of a Corrective Action Plan to address the errors to ensure that the tenant files include all required documentation at the time of recertification began on August 1, 2023. To provide consistency, increase staff knowledge and reduce errors, training began immediately and will continue on an annual and as needed basis. In addition, HAKC will increase quality control file reviews and conduct such reviews on a more frequent basis to identify errors sooner and address the cause of errors quickly to prevent systemic errors. Errors will be identified by error type and the person who made the error. Patterns of errors will be monitored, and additional training provided for similar error types that are frequently repeated and persons who are identified as frequently making errors. Quality reviews will be conducted for all files to ensure that all required documents are in the files. It is anticipated it will take one year to complete the initial file review. After the initial review files will be selected randomly and reviewed according to an established quality control schedule. Each team member will be responsible to collect missing documents identified when completing an annual recertification, interim recertification or change of unit. The Director and Supervisor will assist the Deputy Executive Director and Executive Director in overseeing these corrective actions during the next fiscal year. Name of the contact person responsible for corrective action: Edwin Lowndes Executive Director Planned completion date for corrective action plan to be fully implemented: March 1, 2024.

View Audit 28025

Finding 31193 (2022-003)

Significant Deficiency 2022

Peoria Housing Authority

IL

HUD Housing Programs Subrecipient Monitoring Eligibility

2022-003 Section 8 Housing Choice Vouchers Recommendation: We recommend the Authority implement controls to ensure all tenant file documentation is accurate and available, and that management review their procedures relating to PIC uploads to ensure compliance with HUD's requirements and timelines....

2022-003 Section 8 Housing Choice Vouchers Recommendation: We recommend the Authority implement controls to ensure all tenant file documentation is accurate and available, and that management review their procedures relating to PIC uploads to ensure compliance with HUD's requirements and timelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: 1. The PHA will implementing a Compliance Team to create and enforce a quality assurance plan. The plan will include a 100% file audit of HCV Participant Files to ensure full compliance, and PHA will process all corresponding corrections. 2. The Quality Assurance employees will continue to complete 10% of monthly internal file audits for recertification and 100% of new admissions, to ensure accurate calculations. The Quality Assurance team will also ensure that all proper documentation is present and accurate in all participant files. 3. In addition, PHA will contract a third-party consultant to complete a one-time 100% file audit, then test 10% of participant files, monthly. 4. The HCV Department Team, except for our inspectors, will complete Rent Calculation Training and obtain the exam certification, with a minimum requisite passing score of 80% Additionally, the third-party consultant will provide the HCV Team with technical support required to reconcile file deficiencies noted during the 100% file audit. Planned completion date for the corrective action plan: December 31, 2023; Ongoing Person Responsible: Armeca Crawford, Chief Executive Officer

View Audit 25746

Finding 31191 (2022-002)

Significant Deficiency 2022

Peoria Housing Authority

IL

Equipment & Real Property Management HUD Housing Programs Significant Deficiency

Finding 2022-002 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with account...

Finding 2022-002 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). The PHA understands the importance of accurately tracking both fixed assets and inventory. The PHA will revise policies around fixed assets and inventory and ensure that they are being followed to provide an accurate representation of what the PHA owns. Corrective Action Plan: The Peoria Housing Authority will do a review of the fixed asset listing and bring the necessary dispositions to be approved by the Board of Commissioners to accurately state fixed assets owned by the PHA. This will become an annual process to be completed by the Finance Department in coordination with PHA staff. An annual inventory count will be completed each year at fiscal year-end to ensure that what is reported reflects what is owned by the PHA. An allowance will be set up for any obsolete inventory. This will be addressed during the 2023 calendar year. Person Responsible: Armeca Crawford, Chief Executive Officer Bedrock Housing Consultants in coordination with the PHA Finance Department. Anticipated Completion Date: December 31, 2023

View Audit 25746

Finding 31190 (2022-001)

Significant Deficiency 2022

Peoria Housing Authority

IL

HUD Housing Programs Reporting Significant Deficiency

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with acc...

Finding 2022-001 ? Internal Control over Cash Reconciliations ? Significant Deficiency ? Noncompliance and Qualified at Single Audit Level PHA Response: The Peoria Housing Authority (PHA) has a policy to provide reasonable assurance that the Financial Statements are prepared in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Subsequent to December 31, 2022, the PHA procured the services of Bedrock Housing Consultants who have addressed the timeliness and accuracy of bank reconciliations as well as the monitoring of interfund accounts to ensure they are balanced. The PHA will resolve this issue during the 2023 calendar year. Corrective Action Plan: The Peoria Housing Authority (PHA) will continue to ensure timely and accurate financial reports. Bedrock Housing Consultants will continue to work with the Finance Department to ensure timely and accurate bank reconciliations are being performed. Staff will continue to participate in training in Housing Authority financial management to understand better the industry?s policies, procedures, and practices. The PHA will reconcile monthly all accounts, including accurate reconciliation of all bank accounts as well as balancing interfunds, and when possible reimbursing the amounts due. Any audit adjustments will be made in the proper period and in the accounts detailed per the auditor?s adjusting journal entry report. This will be addressed during the 2023 calendar year. Person Responsible: Armeca Crawford, Chief Executive Officer Bedrock Housing Consultants in coordination with the PHA Finance Department. Anticipated Completion Date: December 31, 2023

View Audit 25746

Finding 31189 (2022-003)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one ...

Finding 2022-003 ?Claims Payments Made Based on Incorrect Calculations of Amounts Reimbursed Status: Under completion. Planned Corrective Action: A review was made by the Foundation?s outside accounting firm engaged to process claims and the errors cited in Finding 2022-003 resulted in only one overpayment to a nursing home. This was confined to a single nursing home that received more than that nursing home would have been entitled to receive under the adopted allocation regime. That nursing home was contacted and has promptly refunded the overage. The Foundation plans to redistribute this amount to other nursing facilities with unmet needs on a ratio and proportion basis. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: October 31, 2023

View Audit 25745 Questioned Costs: $1

Finding 31188 (2022-002)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.329

Finding 2022-002 ?Internal Control Over Reporting Status: Completed. Planned Corrective Action: Management will retain documentation of review of reports. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: September 26, 2023

View Audit 25745

Finding 31187 (2022-001)

Significant Deficiency 2022

Alabama Nursing Home Association Education Foundation

AL

Period of Performance Significant Deficiency Matching / Level of Effort / Earmarking § 200.203 § 200.303

Finding 2022-001 ?Internal Control Over Allowable Activities/Costs and Period of Performance Status: Plan is being formulated. Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the ?Grantor?) to The Alabama Nursing Home Asso...

Finding 2022-001 ?Internal Control Over Allowable Activities/Costs and Period of Performance Status: Plan is being formulated. Planned Corrective Action: The Foundation followed the express instructions of the State of Alabama, Department of Finance (the ?Grantor?) to The Alabama Nursing Home Association Education Foundation (the ?Foundation?), which permitted the Foundation to rely upon the certifications of nursing home applicants that the applicant had or will have sufficient unmet needs related to qualifying purposes due to the COVID-19 pandemic to support the receipt of the various allocations of the herein described COVID-19 Funds. Under the terms of the certification, each applying nursing home further certified that for ten (10) years it would maintain auditable records supporting the unmet need and use of the COVID-19 Funds. This manner of requiring only a certification for the distribution to health care providers is consistent with the requirements the federal government used when distributing an array of emergency funding (e.g., provider relief funds, rural funds, and infection control funds) to health care providers to meet the unmet needs caused by the COVID-19 pandemic. The term ?COVID-19 Funds? means those funds the Foundation received from the Grantor with respect to (i) The CARES Act Corona Virus Relief Funds for the period from January 31, 2020 through December 31, 2021, and (ii) America Rescue Plan Act (ARPA) funds for unmet needs for qualifying purposes incurred or to be incurred during the period March 11, 2021 through December 31, 2024. To provide further assurance that the COVID-19 Funds were properly applied by the nursing home beneficiaries receiving COVID-19 Funds through the Foundation, the Foundation is working with its outside accountants and legal counsel to develop a look-back review plan. The framework of the look-back review plan will be for each nursing home beneficiary that received COVID-19 Funds to submit during the first month of the third quarter of the calendar year 2024, a worksheet similar to the period reporting worksheets that are required by the federal Health Resources & Services Administration (HRSA) to justify the COVID-19 provider relief funds, rural funds, and infection control funds received by health care providers. In addition to these HRSA type worksheets, a more in-depth examination of a sample of nursing homes will be made by randomly selecting 10 nursing homes from a pool of the 30 nursing homes that received the most COVID-19 Funds through the Foundation, plus another 15 nursing homes from the remainder of the pool of beneficiary nursing homes. These randomly selected nursing homes will be required to supply actual documentation supporting the COVID Funds received. This documentation will include invoices, payroll records, revenue journals, and cost reports. Among the provisions of the certifications submitted by each applying nursing home, is an acknowledgement that (i) the nursing home is subject to audit by the applicable State and federal agencies, and the Foundation, (ii) any COVID-19 Funds received through the Foundation and not properly applied must be refunded, and the nursing home will comply with the requirement that it must maintain for ten (10) years auditable records supporting its use of the COVID-19 Funds it received through the Foundation. In the event that it is determined that one or more nursing homes were unable to properly apply the COVID-19 Funds to an unmet need for a qualifying purpose, those COVID-19 Funds will be recouped and either redistributed to any nursing homes that are able show an unmet need continues to exist using a distribution formula consistent with past distributions of refunded COVID-19 Funds, or returned to the Grantor. This redistribution or return to the Grantor will occur no later than December 31, 2024. Person(s) Responsible: John Matson, Acting Executive Director Completion Date: Adoption of the Look-Back Audit Procedures December 31, 2023

View Audit 25745

Finding 31172 (2022-004)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

2022-004 Public and Indian Housing ? Assistance Listing No. 14.850 ? Declaration of Trusts Recommendation: The Authority should ensure they have all required documentation on file to ensure they are in compliance with HUD requirements regarding declaration of trusts. Explanation of disagreement with...

2022-004 Public and Indian Housing ? Assistance Listing No. 14.850 ? Declaration of Trusts Recommendation: The Authority should ensure they have all required documentation on file to ensure they are in compliance with HUD requirements regarding declaration of trusts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority?s counsel has worked with HUD to develop a Declaration of Trust (DOT) report template. Staff have also increased coordination and communication with legal counsel to ensure all DOTs are up to date. Name(s) of the contact person(s) responsible for corrective action: Katrina Sommer Planned completion date for corrective action plan: December 31, 2023

View Audit 35864

Finding 31164 (2022-002)

Significant Deficiency 2022

Housing Authority of St. Louis County

MO

HUD Housing Programs Reporting Significant Deficiency

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagr...

2022-002 Housing Voucher Cluster ? Assistance Listing No. 14.871/14.879 ? PIC Reporting Recommendation: The Authority should implement processes to ensure HUD-50058 submissions are submitted into the PIC system timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since 2022, the Authority has sought comprehensive PIC training from its HUD Field Supervisor, PIC Couch, and EIV Coordinator. During these training events our Authority-HUD team addressed errors dating to 2021 and staff learned to make required corrections in a timely manner. The Authority also has included PIC reporting review as a responsibility for its recently created Housing Choice Voucher (HCV) Floater position. With the assistance of the HCV Floater and oversight by the HCV Director, the Authority addresses any PIC reporting errors effectively and immediately upon receipt. Name(s) of the contact person(s) responsible for corrective action: Nicole O?Dell/Katrina Sommer Planned completion date for corrective action plan: On-going

View Audit 35864

Finding 31148 (2022-001)

None 2022

City of San Bernardino

CA

Subrecipient Monitoring Reporting Significant Deficiency

This corrective action plan is in response to the city's single audit report for the fiscal year ended June 30, 2022, prepared by RAMS. Part Ill Federal Award Findings and Questioned Costs #2022-001 Recommendation: It is recommended that the City implement a tracking system to remind staff of the...

This corrective action plan is in response to the city's single audit report for the fiscal year ended June 30, 2022, prepared by RAMS. Part Ill Federal Award Findings and Questioned Costs #2022-001 Recommendation: It is recommended that the City implement a tracking system to remind staff of the various reports due and respective deadlines. Corrective Action: To ensure compliance for future reporting, staff routes all contracts through DocuSign. Any grant related contract routed through DocuSign will forward a fully executed copy to the Grants Division. Grant related contracts at $30,000 or above will be flagged to inform the applicable department Management Analyst to report the contract to the Federal Funding Accountability and Transparency Act (FFATA) Subaward Report System (FSRS) by the end of the following month. A tracking log will be maintained where applicable contracts will be listed, the deadline date to report in the FSRS, and a date to record when it was completed. This tracking log will be housed in the Grants Division folder on the City's shared drive. Person Responsible for Corrective Action: Grants Division Manager: Mary Alvarez-Gomez Department Management Analyst (various) Anticipated Completion Date for Corrective Action: It should be noted that all contracts within the audit reporting period were reported in the FFATA FSRS by 6/13/23. Corrective Action will be immediately implemented in response to the auditors' recommendation.

View Audit 27596

Finding 31136 (2022-003)

Significant Deficiency 2022

Rape and Abuse Crisis Center of Fargo-Moorehead

ND

Cash Management Significant Deficiency Internal Control / Segregation of Duties

2022-003 U.S. Department of Justice Federal Financial Assistance Listing/Federal CFDA #16.575 Victims of Crime Act (VOCA) Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization's internal control policy relating to the review over the preparati...

2022-003 U.S. Department of Justice Federal Financial Assistance Listing/Federal CFDA #16.575 Victims of Crime Act (VOCA) Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization's internal control policy relating to the review over the preparation of cash draws of federal funds prior to submission was not consistently applied throughout the year. No reviews were noted surrounding the preparation and draws of federal funds prior to submission. Without proper implementation of internal controls over Organization's cash draws, errors could occur and result in the Organization drawing funds in inappropriate amounts or for unallowed costs. We recommend that a member of the Organization's staff who does not prepare the cash draw review the cash draw prior to submission and document that review on a more consistent basis. Status: The Finance Director reviews and approves the prepared cash draw materials prior to submission electronically via email on a consistent basis. Responsibility of: Andrea Lang, Director of Organization Advancement & Jennifer Babcock, Finance Director Estimated Completion Date: Completed. The Finance Director is now reviewing and approving prepared cash draw materials prior to submission.

View Audit 28370

Finding 31131 (2022-001)

Significant Deficiency 2022

City of Lake Lillian

MN

Reporting Significant Deficiency

Auditor Prepared Financial Statements. Name of Contact Person: Kozanna Hirschman, City Clerk. Correction Action: The clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements. Proposed Correction ...

Auditor Prepared Financial Statements. Name of Contact Person: Kozanna Hirschman, City Clerk. Correction Action: The clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure he is aware of financial statement requirements and new pronouncements. Proposed Correction Date: The City Council will implement the above procedures immediately.

View Audit 27974

Finding 31109 (2022-001)

Significant Deficiency 2022

El Valor Corporation

IL

Reporting Allowable Costs / Cost Principles Significant Deficiency

Action taken in response to finding: Management will emphasize the completion of the reports by the applicable due dates by prioritizing this compliance requirement. We have been down a finance position and we were not able to consistently submit the SF-425 reports by the applicable due dates. This...

Action taken in response to finding: Management will emphasize the completion of the reports by the applicable due dates by prioritizing this compliance requirement. We have been down a finance position and we were not able to consistently submit the SF-425 reports by the applicable due dates. This coming year this compliance requirement will be our focus and we will maintain documentation of the initial submission dates. Name of the contact person responsible for corrective action: Carmen Ziegler, CFO Planned completion date for corrective action plan: February 28, 2023

View Audit 26578

Finding 31048 (2022-002)

Significant Deficiency 2022

Okanogan Behavioral Healthcare

WA

Questioned Costs Allowable Costs / Cost Principles Period of Performance

Corrective Action Plan: Okanogan Behavioral HealthCare (OBHC) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...

Corrective Action Plan: Okanogan Behavioral HealthCare (OBHC) respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The monthly close checklist has been modified to include a payroll transaction process for the September close for this grant. This is the sole grant that requires a second grant closure process. Name of the contact person responsible for corrective action: Patty Branch, Finance Manager Planned completion date for corrective action plan: October 2022 for the September close and grant invoice submission.

View Audit 27021 Questioned Costs: $1

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