Corrective Action Plans

Finding 574641 (2024-001)

Significant Deficiency 2024

CA

Special Tests & Provisions Significant Deficiency

Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selecte...

Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selected for testing Friends of Family Health Center incorrectly applied the discount or were put in the incorrect category based on income and family size. Response One error in calculating a patient’s income with 40 others is a minor 2.5% error margin. FOFHC will have a quarterly training course on how to properly use the various income level tables provided to the front office staff. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025

View Audit 364910

Finding 574639 (2024-003)

Significant Deficiency 2024

Tazewell County, Illinois

IL

Procurement, Suspension & Debarment Significant Deficiency

Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all ...

Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all vendors working on projects funded by federal grant dollars.

View Audit 364907

Finding 574627 (2024-003)

Significant Deficiency 2024

Aurora Housing Authority

CO

Special Tests & Provisions HUD Housing Programs Significant Deficiency

Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...

Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing

View Audit 364890

Finding 574624 (2024-002)

Significant Deficiency 2024

Aurora Housing Authority

CO

Eligibility HUD Housing Programs Significant Deficiency

Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...

Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing

View Audit 364890

Finding 574590 (2024-002)

Significant Deficiency 2024

Minnesota Prairie County Alliance

MN

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...

Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.

View Audit 364815

Finding 574589 (2024-001)

Significant Deficiency 2024

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...

Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.

View Audit 364815

Finding 574588 (2024-002)

Significant Deficiency 2024

Fremont County, Wyoming

WY

Procurement, Suspension & Debarment Significant Deficiency

2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being ...

2024-002 Significant Deficiency-Procurement Fremont County Response. Julie Freese Fremont County Clerk. While the county does not have an independent "Procurement Policy", we have been following our Capital Revolving Procedures which include bidding criteria based on pricing and types of bids being sought. A Procurement policy has been obtained from another county to review. It is the intent of the county to prepare its own "Procurement Policy" during a policy work session, coming up this fall. Treasurer Anderson and Clerk Freese also toll a 2-day Procurement training put on by the Federal Grants Training Program this summer. In the meantime, the county will continue to follow all federal regulations for every grant we receive as per each particular project dictates.

View Audit 364810

Finding 574587 (2024-001)

Significant Deficiency 2024

Fremont County, Wyoming

WY

Reporting Significant Deficiency § 200.501

Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to as...

Finding 2024-001: Significant Deficiency - Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to assist with audit preparation. This was in addition to $30,000 set aside in the county treasurer's budget for audit consulting. The county commissioners hired an individual in September 2024. That individual left employement with the county in November 2024 and the position was not refilled through the end of fiscal year 2025. The remainder of the FY2024 audit preparation was completed in-house. Due to reductions in revenue and budget constraints, both the $100,000 allocation for a new employee and the $30,000 for consulting services were cut from the commissioners' and treasurer's budgets, so the county is pivoting on audit preparation resposibilities and expanding the number of in-house employees working on different facets of the preparation. With the exception of the CPA that was on staff for two months, the rest of the finance staff has been stable for at least two years and have grown in their knowledge of county finances. We are utilizing 6-7 different staff members on parallel tasks with oversight and assistance from the county treasurer and clerk. We are confident that the audit preparation for FY2025 will be completed months earlier such that trial balances and supporting documentation will be available to our auditors in time to meet the federal submission deadline.

View Audit 364810

Finding 574482 (2024-003)

Significant Deficiency 2024

Municipality of Gurabo

PR

HUD Housing Programs Reporting Significant Deficiency

We are working in implementing adequate extaernal and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.

View Audit 364800

Finding 574464 (2024-002)

Significant Deficiency 2024

Municipality of Gurabo

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512

We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.

View Audit 364800

Finding 574172 (2024-001)

Significant Deficiency 2024

Barron County Housing Authority

WI

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit...

Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the calculations to ensure calculations are done and maintained in the files and implement processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Bob Kazmierski Planned completion date for corrective action plan: December 31, 2024

View Audit 364743

Finding 574145 (2024-002)

Significant Deficiency 2024

Connected Lane County

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.212 § 200.512

Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in ...

Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in paper files in the finance department for easy access during the course of the audit. Person(s) Responsible: Mary Bell, Finance Manager Anticipated Completion Date: September 1, 2025

View Audit 364714

Finding 574144 (2024-004)

Significant Deficiency 2024

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328 § 200.329

Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.

View Audit 364712

Finding 574119 (2024-001)

Significant Deficiency 2024

Brockton Housing Authority

MA

Questioned Costs HUD Housing Programs Eligibility

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing

View Audit 364699 Questioned Costs: $1

Finding 574080 (2024-002)

Significant Deficiency 2024

Chippewa County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and upd...

Finding Number: 2024-002 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Michelle Trulock, Financial Assistance Supervisor Corrective Action Planned: Cases where there was an income discrepancy have been reviewed and updated. Peacetime instructions used during COVID are no longer in place. MAXIS cases have reverted to pre-pandemic processing and will be reviewed and updated. Specific income calculations were reviewed with staff. Supervisor will promote annotation on documents for clarification, as well as clear and concise case noting. Desk reviews are completed periodically for review of income, assets and citizenship and all transfer in cases are reviewed for the like. Supervisor will request that each worker review citizenship (STAT/ MEMB/MEMI and imaging) at healthcare renewal month to ensure accuracy. Policy and procedure review for staff on reviewing forms for asset information. This also relates to the self-attestation of cash on the review forms. Anticipated Completion Date: On 06/03/2025, Supervisor met with staff to discuss the results of the audit and train and review policy and procedure on best practices for processing and maintenance of healthcare cases. This will be an ongoing agenda item at monthly unit meetings.

View Audit 364657

Finding 574061 (2024-002)

Significant Deficiency 2024

All Nations Health Center, Inc.

MT

Reporting Significant Deficiency § 200.512

All Nations Health Center will identify appropriate resources and implement procedures needed for timely submission of the Single Audit report in the future.

View Audit 364635

Finding 574053 (2024-004)

Significant Deficiency 2024

Easter Seals Serving Dc/md/va

MD

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...

Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy

View Audit 364634

Finding 574051 (2024-001)

Significant Deficiency 2024

City of Dover

NH

Reporting Allowable Costs / Cost Principles Cash Management § 200.510

The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Direct...

The City's Finance Department, in preparing the annual SEFA, will have a review and approval process. The SEFA will be prepared by the accounting division based upon federal grant expenditures recorded in the City's General Ledger. The SEFA document will then be reviewed by the Deputy Finance Director and approved by the Finance Director prior to submission to the auditing firm. In addition to federal grants adopted as part of the City's annual operating budget, after adoption of the annual operating budget any federal grant approved by City Council for acceptance and expenditure will be maintained in the City's electronic archival system. The SEFA will be compard to the list of budgeted grants and the grants accepted after adoption of the annual operating budget to ensure grants are appropriately reported on SEFA.

View Audit 364631

Finding 574046 (2024-002)

Significant Deficiency 2024

City of Dover

NH

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.303

When submitting SLFRF Project & Expenditure Report, the City will break out expenditures into more detailed groupings of closely related activities. Past reports were submitted as one project which falls under SLFRF 6-Revenue Replacement 6.1-Provisions of Government Services.

View Audit 364631

Finding 574021 (2024-002)

Significant Deficiency 2024

The Food Trust

PA

Allowable Costs / Cost Principles Reporting Significant Deficiency

During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...

During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.

View Audit 364615

Finding 574016 (2024-003)

Significant Deficiency 2024

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD guidelines require Project cash to be maintained in financial institutions, which meet minimum GNMA ratings, when balances exceed federal insurance limits. Condition: The Organization maintains cash balances in excess of federally insured limits in a financial institution that does not meet HUD guidelines. Questioned costs: None Context: The cash balance as of December 31, 2024 was approximately $740,000, held in two financial institutions, which exceeded federal insurance limits by approximately $470,000. Cause: As the Organization is a community based non-profit organization, management considers supporting a local bank to be a worthwhile endeavor. Effect: No negative effect was discovered during the audit. Repeat Finding: No. Recommendation: The Organization should transfer all funds to a financial institution that meets HUD guidelines. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevins mission in the community. Given Nevins current financial struggles, the balance in the bank seldom exceeds the $250,000.00 threshold.

View Audit 364597

Finding 574014 (2024-002)

Significant Deficiency 2024

Henry C. Nevins Home, Inc.

MA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...

Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires the Organization to make mortgage payments on a timely basis. Condition: Mortgage payments for February, March, April and May 2024 were not received by the mortgage company promptly. Questioned costs: None Context: February, March, April and May 2024 mortgage payments were received by the mortgage company subsequent to the 15th of the following month, which is considered late per HUD guidelines. Cause: Mortgage payments were being funded with approved withdrawals from reserve accounts which delayed timing of payment. Effect: Late charges were assessed to the Project. Repeat Finding: No. Recommendation: Mortgage payments should be made by the due date. Action Taken: Nevins was in touch with HUD monthly and developed a repayment plan but could not follow through. Nevins engaged with Alliance Healthcare for Accounts Receivable assistance in the fall of 2024 and then entered into a Management agreement with Alliance Healthcare in June of 2025.

View Audit 364597

Finding 573908 (2024-002)

Significant Deficiency 2024

Sicangu Oyate Ho, INC

SD

Reporting Significant Deficiency

Management Response: Our CPA will train our Accounting Tech to complete bank reconciliations. A huge part of the GL not being updated is due to credit card expenditures and not utilizing the software to update when there is credit card usage. We will begin using the School Accounting Software to tra...

Management Response: Our CPA will train our Accounting Tech to complete bank reconciliations. A huge part of the GL not being updated is due to credit card expenditures and not utilizing the software to update when there is credit card usage. We will begin using the School Accounting Software to track credit card expenditures so we won't have to wait until we get credit card statements to reconcile. Anticipated Completion Date: September 30, 2025 - we will begin utilizing the credit card feature in the Accounting Software immediately. Responsible Party: Accounts Payable Personnel; Accounting Tech will work with CPA's ; Business Manager will have oversight for completion.

View Audit 364557

Finding 573884 (2024-007)

Significant Deficiency 2024

Northern Lakes Community Mental Health

MI

Cash Management Significant Deficiency

Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective...

Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that expenses listed in reports are supported by our books and records. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Finding 573883 (2024-006)

Significant Deficiency 2024

Northern Lakes Community Mental Health

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...

Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

View Audit 364530

Corrective Action Plans

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