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Corrective Action Plans

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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.
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 Questioned Costs Allowable Costs / Cost Principles § 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.
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
Finding 573840 (2024-001)
Significant Deficiency 2024
Central Tribes of the Shawnee Area, Inc.
OK
Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
View Audit 364487
Finding 573782 (2024-001)
Significant Deficiency 2024
Commonwealth Institute of Funeral Service
TX
Student Financial Aid Questioned Costs Special Tests & Provisions
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.
View Audit 364456
Finding 573781 (2024-002)
Significant Deficiency 2024
Opportunity Alabama, Inc.
AL
Allowable Costs / Cost Principles Cash Management Significant Deficiency
Finding 2024-002 Lack of documentation – Significant Deficiency Corrective Action Plan: In June of 2025, Opportunity Alabama Inc created a formal signoff procedure for our bank reconciliation process that includes steps for reviewing at the transaction level for expenditures related to grants. ...
Finding 2024-002 Lack of documentation – Significant Deficiency Corrective Action Plan: In June of 2025, Opportunity Alabama Inc created a formal signoff procedure for our bank reconciliation process that includes steps for reviewing at the transaction level for expenditures related to grants. Contact person: Megan Warren, Chief Compliance Officer and Director of Accounting; (205) 319- 6688; megan@opportunityalabama.com
View Audit 364454
Finding 573780 (2024-003)
Significant Deficiency 2024
Elkhorn Rural Public Power District
NE
Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303
Federal Agency Name: Department of Homeland Security Pass‐Through Entity: State of Nebraska Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: Certain line items in the reports submitted for the quarters ended 3/31/2024 an...
Federal Agency Name: Department of Homeland Security Pass‐Through Entity: State of Nebraska Office of Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: Certain line items in the reports submitted for the quarters ended 3/31/2024 and 6/30/2024 contained costs from the incorrect period. Corrective Action Plan: The State of Nebraska requires quarterly reporting on FEMA funded projects. The due date of the report is on the 15th of the month following the end of the quarter. Due to this timing and the month‐end closing process of Elkhorn RPPD’s financials, the costs for work order costs related to payroll benefits and any overheads are not included in the quarterly project costs. These are submitted the next quarterly report. Responsible Individuals: Carmen Christensen, CFO/Office Manager Anticipated Completion Date: Ongoing through the end of the grant award dated 9/17/2024.
View Audit 364452
Finding 573737 (2024-002)
Significant Deficiency 2024
Iowa Northland Regional Housing Authority
IA
Internal Control / Segregation of Duties Significant Deficiency
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
View Audit 364399
Finding 573736 (2024-001)
Significant Deficiency 2024
Iowa Northland Regional Housing Authority
IA
Reporting Significant Deficiency Internal Control / Segregation of Duties
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
View Audit 364399
Finding 573667 (2024-004)
Significant Deficiency 2024
Trilogy, Inc.
IL
Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303
Action taken in response to finding: Trilogy will be conducting a comprehensive review of payroll records and timesheets for all employees whose salaries are charged to the grant. This includes verifying that the pay periods align with the grant’s allowable cost period and that supporting documentat...
Action taken in response to finding: Trilogy will be conducting a comprehensive review of payroll records and timesheets for all employees whose salaries are charged to the grant. This includes verifying that the pay periods align with the grant’s allowable cost period and that supporting documentation is complete and accurate. This will ensure that personnel costs are consistently reconciled with grant pay periods before charges are submitted for reimbursement. Relevant staff members will receive refresher training on grant compliance requirements, specifically focusing on documentation standards for personnel costs and the importance of aligning pay periods with grant terms. Trilogy will implement periodic internal audits to monitor compliance and ensure continued accuracy in personnel cost allocations. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes & Hagar Buster Planned completion date for corrective action plan: July 2025
View Audit 364306
Finding 573666 (2024-003)
Significant Deficiency 2024
Trilogy, Inc.
IL
Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.403
Action taken in response to finding: Trilogy will revise our monthly invoicing procedures to include a standardized step for verifying the indirect cost calculation. This will include recalculation of the indirect cost rate using actual monthly expenditures reflected in the grant invoices submitted...
Action taken in response to finding: Trilogy will revise our monthly invoicing procedures to include a standardized step for verifying the indirect cost calculation. This will include recalculation of the indirect cost rate using actual monthly expenditures reflected in the grant invoices submitted for reimbursement. This recalculation will ensure that indirect costs are proportionate and accurately reflect the approved rate and allowable base. Relevant staff members will receive training on proper indirect cost calculation methods, and how to apply the rate to the correct base and reconcile with monthly expenditures. We will implement a quarterly review of indirect cost charges to ensure continued accuracy and compliance. Any discrepancies will be addressed promptly and adjusted as needed. Name(s) of the contact person(s) responsible for corrective action: Shunita Rhodes & Hagar Buster Planned completion date for corrective action plan: July 2025
View Audit 364306 Questioned Costs: $1
Finding 573543 (2024-001)
Significant Deficiency 2024
Friendly Temple Apartments Ii, INC
MO
Questioned Costs HUD Housing Programs Significant Deficiency
Management agrees with this finding and the overpayment was corrected in March 2024. Management will review internal controls and implement a review process to only pay expenses already incurred to avoid future overpayments.
Management agrees with this finding and the overpayment was corrected in March 2024. Management will review internal controls and implement a review process to only pay expenses already incurred to avoid future overpayments.
View Audit 364277 Questioned Costs: $1
Finding 573542 (2024-001)
Significant Deficiency 2024
West End Elderly Housing Corporation
MO
Questioned Costs HUD Housing Programs Significant Deficiency
Management agrees with this finding and the overpayment will be corrected. Management will review internal controls and implement a review process to only pay expenses already incmTed to avoid future overpayments.
Management agrees with this finding and the overpayment will be corrected. Management will review internal controls and implement a review process to only pay expenses already incmTed to avoid future overpayments.
View Audit 364276 Questioned Costs: $1
Finding 573541 (2024-001)
Significant Deficiency 2024
Aleutians East Borough
AK
Reporting Questioned Costs Subrecipient Monitoring
Finding 2024-001 Deadline for Federal Single Audit – Noncompliance and Internal Control Over Compliance – Significant Deficiency Corrective Action Plan Borough Management acknowledges that the SF-SAC was filed late for Fiscal Year 2024 due to unforeseen financial statement disclosure requirements. A...
Finding 2024-001 Deadline for Federal Single Audit – Noncompliance and Internal Control Over Compliance – Significant Deficiency Corrective Action Plan Borough Management acknowledges that the SF-SAC was filed late for Fiscal Year 2024 due to unforeseen financial statement disclosure requirements. As those disclosures have been resolved during Fiscal Year 2024, we do not anticipate any such issues for Fiscal Year 2025. Expected Completion Date All matters relating to the financial statement disclosures were made prior to June 30, 2025.
View Audit 364271
Finding 573441 (2024-001)
Significant Deficiency 2024
Corn Belt Power Cooperative
IA
Reporting Significant Deficiency
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Department of Homeland Security and Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Cooperative does not have an internal control system ...
Federal Agency Name: Department of Homeland Security Pass-Through Entity: State of Iowa Department of Homeland Security and Emergency Management Assistance Listing Number: 97.039 Program Name: Hazard Mitigation Grant Program Finding Summary: The Cooperative does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule and accompanying notes to the schedule. Corrective Action Plan: As this is the Cooperative’s first single audit related to a mitigation project, the Auditor has been requested to prepare the schedule of expenditures of federal awards. In future audits, the Cooperative will assume responsibility for preparing this schedule. The Accountant III will gather the necessary documentation and draft the statement. The Vice President of Finance & Administration will review both the documentation and the statement. Once reviewed, both the Accountant III and the VP will sign off on the final version. Responsible Individual(s): Faith Warden, VP, Finance & Administration and Sam Moore, Accountant III Anticipated Completion Date: July 2025
View Audit 364186
Finding 573408 (2024-001)
Significant Deficiency 2024
International Development Enterprises and Subsidiaries
CO
Questioned Costs Subrecipient Monitoring Reporting § 200.303
Identifying Number: 2024-001: FFATA Controls Finding: There is no internal control in place over Federal Funding Accountability and Transparency Act (FFATA) reporting submissions, which is a direct and material compliance requirement over USAID federal awards. Corrective Actions Taken or Planned: ...
Identifying Number: 2024-001: FFATA Controls Finding: There is no internal control in place over Federal Funding Accountability and Transparency Act (FFATA) reporting submissions, which is a direct and material compliance requirement over USAID federal awards. Corrective Actions Taken or Planned: Name of Responsible Official: John Passauer, Vice President of Finance Anticipated Completion Date: December 31, 2025 Views of Responsible Officials and Planned Corrective Action: 1. Provide training on Federal Funding Accountability and Transparency Act (FFATA) reporting submissions for all Country Directors, grant program managers and Finance Directors. 2. Monitor ongoing compliance on a quarterly basis for any remaining active grants.
View Audit 364163
Finding 573382 (2024-004)
Significant Deficiency 2024
County of Sutter
CA
Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking
Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Development Services sent certified letters to loan recipients and retained certified or returned mail. In some cases, the department sent up to 4 letters and ph...
Name of Contact Person Nathan Black, Auditor-Controller Management's Response and Corrective Action The County agrees with the finding. Development Services sent certified letters to loan recipients and retained certified or returned mail. In some cases, the department sent up to 4 letters and physically verified the houses are still occupied. Code Enforcement staff also hand delivered letters to some of the non-responsive loan recipients. Moreover, the Department has secured the services of an outside consultant, Adams Ashby Group, to review and assist in efforts to comply with the loan requirements and provide their outside opinion on best practice in handling loans. Lastly, the Department is working with County Administrator's Office, Treasurer-Tax Collector's Office, and County Counsel on proper and legal way to handle sold properties, delinquent taxes, or simply not responding to the County's correspondence and requests. Proposed Completion Date Ongoing process.
View Audit 364158
Finding 573357 (2024-012)
Significant Deficiency 2024
Leech Lake Tribal College
AZ
Questioned Costs Significant Deficiency Internal Control / Segregation of Duties
The Department will enforce policies and procedures to ensure that payroll records are being consistently maintained.
The Department will enforce policies and procedures to ensure that payroll records are being consistently maintained.
View Audit 364132
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