Corrective Action Plans

Finding 392602 (2021-001)

Significant Deficiency 2021

AK

Subrecipient Monitoring Reporting Significant Deficiency

Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that ...

Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that our future audits are completed in time to file the form SF-SAC within the required nine months of our fiscal year end (9/30). Our corrective action plan includes: - Closing the fiscal year books within 90 days after our fiscal year end (excluding any required adjusting journal entries that may be necessary). - Scheduling our audit to occur within 100 days after our fiscal year end. - Obtaining a final audit report prior to the end of June following our fiscal year end. Proposed Completion Date: We are anticipating that the completion date of the above corrective action plan will be for Fiscal Year 2023.

View Audit 302903

Finding 392595 (2021-001)

Significant Deficiency 2021

Self Regional Healthcare and Affiliates

SC

Questioned Costs Internal Control / Segregation of Duties Eligibility

Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed o...

Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed our processes for inclusion of only expenditures that have not been reimbursed. Similarly we included costs of COVID testing expenditures however, some of those costs were either billed to patients or reimbursed from other sources. We have corrected that process also. Completion Date: January 2024.

View Audit 302889 Questioned Costs: $1

Finding 392368 (2021-003)

Significant Deficiency 2021

Scott County Hospital

KS

Reporting Significant Deficiency

The Hospital selected option ii for reporting budgeted versus actual revenue for the computation of lost revenues for 2020 and the first two quarters in 2021. The Hospital’s budget through June 2020 was approved by March 27, 2020 but the budget for July 2020 to June 2021 was approved subsequent to ...

The Hospital selected option ii for reporting budgeted versus actual revenue for the computation of lost revenues for 2020 and the first two quarters in 2021. The Hospital’s budget through June 2020 was approved by March 27, 2020 but the budget for July 2020 to June 2021 was approved subsequent to March 27, 2020. Accordingly, the Hospital should have selected option iii, a reasonable alternative methodology, when reporting lost revenue. Management will review procedures to ensure that lost revenues are reported under method iii on future PRF report submissions.

View Audit 302715

Finding 392366 (2021-001)

Significant Deficiency 2021

Scott County Hospital

KS

Reporting Significant Deficiency

The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-C...

The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-COVID related service should have been excluded from the comparison period. The Hospital will correct the lost revenue calculations to exclude new non-COVID related patient care revenues in both the baseline and comparison periods in all subsequent PRF reporting.

View Audit 302715

Finding 392314 (2021-006)

Significant Deficiency 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

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

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...

2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.

View Audit 302660

Finding 392308 (2021-004)

Significant Deficiency 2021

Klamath Health Partners, Inc. Dba: Klamath Open Door Family Practice

OR

Cash Management Internal Control / Segregation of Duties Reporting

2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is ...

2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure documentation and records are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls.. Furthermore, a controller has been hired to prepare the reports and oversee cash management activities. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: March 11, 2024

View Audit 302660

Finding 392156 (2021-003)

Significant Deficiency 2021

Housing Authority of the City of Renton

WA

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to...

Finding 2021-003 a. Comments on the Finding and Each Recommendation: Management agrees with both the finding and recommendations. b. Action(s) Taken or Planned on the Finding The management overseeing the process has been completely replaced to ensure a fresh perspective and unwavering dedication to implementing robust internal controls. To address the shortcomings identified in Finding 2021-003, the Authority commits to a targeted action plan aimed at ensuring timely compliance with reporting requirements. Central to our approach is the engagement of a fee accountant, recognized for expertise in HUD reporting and public housing financial management. This specialist will be tasked with overseeing and streamlining our reporting processes. By leveraging this expertise, we aim to quickly rectify past reporting lapses and ensure future submissions are timely and compliant with HUD requirements. The new fee accountant will conduct a comprehensive review of our current reporting mechanisms, identify bottlenecks, and implement best practices tailored to our operations. This decisive action, centered around the expertise of the newly appointed fee accountant, demonstrates our commitment to enhancing our financial management practices and aligning with HUD's reporting expectations. Through these measures, we anticipate not only meeting HUD's deadlines but also setting a new standard for operational excellence within our Authority.

View Audit 302365

Finding 392155 (2021-002)

Significant Deficiency 2021

Housing Authority of the City of Renton

WA

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Finding 2021-002 a. Comments on the Finding and Each Recommendation: We concur with the finding and agree with the recommendations. b. Action(s) Taken or Planned on the Finding In response to this finding regarding non-compliance in Housing Quality Standards (HQS) enforcement, the new management tea...

Finding 2021-002 a. Comments on the Finding and Each Recommendation: We concur with the finding and agree with the recommendations. b. Action(s) Taken or Planned on the Finding In response to this finding regarding non-compliance in Housing Quality Standards (HQS) enforcement, the new management team at the Authority has developed a focused corrective action plan. This plan includes comprehensive staff training on HUD regulations and HQS compliance, with a completion target of March 2024. Concurrently, our CEO and Director of Programs Administration will oversee the revision and implementation of enhanced HQS monitoring procedures, aiming for completion by March 2024. This involves updating inspection protocols, instituting regular internal audits for compliance, and establishing clear procedures for re-inspections, HAP abatement, and voucher cancellations. Recognizing the oversight of the previous management, the new team is committed to rectifying these issues and ensuring ongoing compliance. We will maintain thorough documentation of all actions taken and provide regular updates on the progress. The HCV Coordinator will be responsible for ongoing compliance monitoring and reporting, ensuring that the program adheres to HUD's Housing Quality Standards and effectively serves its participants. This approach reaffirms our dedication to upholding the integrity and effectiveness of the Housing Voucher Cluster programs.

View Audit 302365

Finding 375834 (2021-004)

Significant Deficiency 2021

California Asian Pacific Chamber of Commerce

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.400

Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system...

Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: The ERP system will include electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. An indirect cost pool allocation structure will be designed and implemented to properly allocate the allowable indirect costs to each work effort. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system

View Audit 294918

Finding 374692 (2021-001)

Significant Deficiency 2021

Tuscumbia City Board of Education

AL

Allowable Costs / Cost Principles Reporting Significant Deficiency

Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Pac...

Recommendations: The Board should strive to submit the Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end. Views of Responsible Officials and Planned Corrective Actions: The Board will strive to submit its Single Audit Reporting Package to the federal audit clearinghouse no later than nine months after the fiscal year end for all future funds received from the federal government.

View Audit 294382

Finding 374621 (2021-003)

Significant Deficiency 2021

Saint Charles County, Missouri

MO

Subrecipient Monitoring Reporting Significant Deficiency

FFATA Reporting – Community Development Block Grants U.S. Department of Housing and Urban Development Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports and training employees...

FFATA Reporting – Community Development Block Grants U.S. Department of Housing and Urban Development Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports and training employees on the FFATA reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all of the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website. Name(s) of the contact person(s) responsible for corrective action: Tracy Bayne Planned completion date for corrective action plan: September 30, 2024

View Audit 294294

Finding 374620 (2021-002)

Significant Deficiency 2021

Saint Charles County, Missouri

MO

Subrecipient Monitoring HUD Housing Programs Reporting

FFATA Reporting - Housing Choice Voucher U.S. Department of Housing and urban Development Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency ACT (FFATA) reports and training employees on the FFAT...

FFATA Reporting - Housing Choice Voucher U.S. Department of Housing and urban Development Recommendation: We recommend the agency implement a process that includes tracking timely submission of the Federal Funding Accountability and Transparency ACT (FFATA) reports and training employees on the FFATA reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all of the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website. Name(s) of the contact person(s) responsible for corrective action: Tracy Bayne Planned completion date for corrective action plan: September 30, 2022

View Audit 294294

Finding 370602 (2021-015)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Material Weakness Significant Deficiency Matching / Level of Effort / Earmarking

Finding 2021-015 Commingling CRF and ARP Funds Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director Action: Ensure that funds are separated so that federal funds are spent appropriately. Anticipated Completion Date: Ongoing

View Audit 292271

Finding 370593 (2021-014)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Eligibility Material Weakness Significant Deficiency

Finding 2021-014 Eligibility Individual(s) Responsible: Paul Austin, Program Director with supervision from Grace Ross, Tribal Treasurer Action: Will ensure that all patients provide eligibility documentation. Anticipated Completion Date: September 2024

View Audit 292271

Finding 370591 (2021-012)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding 2021-012 Program Income Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director, Program Directors Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: September 2023

View Audit 292271

Finding 370586 (2021-009)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2021-009 Reporting Individual(s) Responsible: Grace Ross, Tribal Treasurer, Tribal Administrator Action: Reviewing reporting requirements with department heads and reviewing reports submitted. Anticipated Completion Date: April 2024

View Audit 292271

Finding 370584 (2021-011)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency

Finding 2021-011 Allowable Costs and Activities Individual(s) Responsible: Grace Ross, Tribal Treasurer, Accounting Director Action: Current Tribal Council will ensure that all documentation is maintained as backup for all purchases and payroll items. Anticipated Completion Date: September 2023

View Audit 292271

Finding 370583 (2021-010)

Material Weakness 2021

Kickapoo Tribe in Kansas

KS

Procurement, Suspension & Debarment Cash Management Material Weakness

Finding 2021-010 Special Tests and Provisions Individual(s) Responsible: Grace Ross, Tribal Treasurer, Program Directors Action: Be able to provide documentation to show that federal funds were fully protected and insured. Review annual and quarterly reporting to ensure timely filing. Antici...

Finding 2021-010 Special Tests and Provisions Individual(s) Responsible: Grace Ross, Tribal Treasurer, Program Directors Action: Be able to provide documentation to show that federal funds were fully protected and insured. Review annual and quarterly reporting to ensure timely filing. Anticipated Completion Date: April 2024

View Audit 292271

Finding 369779 (2021-002)

Significant Deficiency 2021

Housing Authority of the Birmingham District

AL

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Recommendation: The Authority should implement additional controls related to monitoring timelines and review and retention of tenant’s inspection. The support of abatement, inspection results should be kept in the tenant file or centralized location. We recommend management should designate one per...

Recommendation: The Authority should implement additional controls related to monitoring timelines and review and retention of tenant’s inspection. The support of abatement, inspection results should be kept in the tenant file or centralized location. We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement. Action taken in response to finding: The Authority will implement additional controls related to monitoring timelines and review and retention of tenant’s inspection. During the year, the Authority faced turnover in the Section 8 department, which caused internal controls to not operate effectively. Name of the contact person responsible for corrective action: Dontrelle Young Foster, Executive Director Planned completion date for corrective action plan: We expect to have the finding resolved by issuance of next year's audit. If the U.S. Department Housing and Urban Development has questions regarding this plan, please call Dontrelle Foster at (205) 521-0623.

View Audit 291312 Questioned Costs: $1

Finding 369636 (2021-002)

Significant Deficiency 2021

Mobile Housing Authority

AL

Eligibility HUD Housing Programs Significant Deficiency

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

MHA will review and enhance as necessary the program’s existing quality control (QC) daily data validation reports to include a measure that cross-checks existing reports in the Yardi system of record and aids in validating data routinely submitted to HUD’s PIC system. In 2023, MHA implemented a Housing Specialist-II team lead to oversee staff processing annual reexaminations in accordance with 24 CFR 982.516. This team member is responsible for ensuring families are notified in a timely manner and if they do not comply with the annual reexamination requirement, they receive termination notices in compliance with HUD and MHA Administrative Plan requirements. This information will be maintained in the program file. Responsible Person: Magdalene Watkins, Program Administrator Projected Completion Date: March 31, 2024

View Audit 291023

Finding 369635 (2021-001)

Significant Deficiency 2021

Mobile Housing Authority

AL

Internal Control / Segregation of Duties HUD Housing Programs Reporting

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

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

View Audit 291023

Finding 369352 (2021-002)

Significant Deficiency 2021

Legacy Senior Services

MN

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submi...

Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 1 and Period 2 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: When summarizing eligible costs and lost revenue for submission, a secondary review of the summary spreadsheet prepared from the underlying supporting expense records will be documented. Before reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: 2/1/2024

View Audit 290581

Finding 11921 (2021-007)

Significant Deficiency 2021

Redevelopment Authority of the County of Berks

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

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 p...

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 15886

Finding 11003 (2021-002)

Significant Deficiency 2021

Cornwall Manor

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Manor agrees with the finding and misinterpreted the guidance. The Manor agrees that they should have selected option iii as independent living revenues were not affected and personal care was undergoing renovations and thus the comparison of actual personal care revenues was not appropriate. ...

The Manor agrees with the finding and misinterpreted the guidance. The Manor agrees that they should have selected option iii as independent living revenues were not affected and personal care was undergoing renovations and thus the comparison of actual personal care revenues was not appropriate. Management will correct the error in future filings.

View Audit 14852

Finding 10970 (2021-006)

Significant Deficiency 2021

Oregon Coalition Against Domestic & Sexual Violence

OR

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

Contact person(s) responsible: Executive Director Vanessa Timmons; Associate Director Keri Moran-Kuhn; Accounting Manager Linda Koonce Corrective Action Planned: During this time OCADSV went through several temporary fiscal staff and one permanent hired staff that had made mistakes, with the effect ...

Contact person(s) responsible: Executive Director Vanessa Timmons; Associate Director Keri Moran-Kuhn; Accounting Manager Linda Koonce Corrective Action Planned: During this time OCADSV went through several temporary fiscal staff and one permanent hired staff that had made mistakes, with the effect of having to make adjustments in order to attempt to close accounting records. Controls have been put into place and permanent accounting manager is in place. Anticipated Date of Completion: 01-24-2022

View Audit 14814

Corrective Action Plans

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