Corrective Action Plans

Finding 323 (2023-001)

Significant Deficiency 2023

Mary Lee Flagship

TX

Subrecipient Monitoring

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertif...

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 202 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases.

View Audit 626

Finding 236 (2023-003)

Significant Deficiency 2023

Sunrise Community Health

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement wi...

Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilitzed for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization's enrollment and billing department will work together to identify when any errors occur based on the documentation the patient provides. The enrollment team will verify the rate, and the billing and coding team will begin checking to ensure the rate that the patient was screened for is the rate the patient is being charged for and that the correct discoutn applies.

View Audit 487

Finding 221 (2023-002)

Material Weakness 2023

Mary Lee Charles Place

TX

HUD Housing Programs Subrecipient Monitoring

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertif...

Management agrees with the finding and will begin an independent review of each tenant file to include examination of EIV reports to determine if there are any discrepancies and take corrective measures. Leasing office staff will undergo additional HUD 811 training regarding the initial and recertification process. Additionally, management is staffing the property with a dedicated property manager that will be responsible for reviewing tenant files for compliance with HUD procedures including uses of EIV reports and ensure supporting documentation is maintained in each tenant’s file prior to signing new or amended leases. Estimated completion date is November 30, 2023.

View Audit 460

Finding 216 (2023-001)

None 2023

Chowan University

NC

Student Financial Aid Matching / Level of Effort / Earmarking Subrecipient Monitoring

Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and docum...

Name of Responsible Individual: Ruth Casper & Stephanie Furlough Corrective Action: The University Financial Aid Office has restructured the disbursement process as noted below: • Staff members will be retrained on the importance of timely reporting and record compliance. • A disbursement and documentation process will be created to track, manage and reconcile the disbursement requests sent to COD. This process will aidin recognizing approved disbursements, rejected requests, and posting of disbursements. • The disbursement and reconciliation log will be reviewed by the Asst. Vice President for Student Financial Services as well as the Asst Vice President for Analytics & Audit. Anticipated Completion Date: The disbursement procedures will be monitored on an ongoing basis.

View Audit 409

Finding 209 (2023-001)

Significant Deficiency 2023

University of Health Sciences and Pharmacy in St Louis

MO

Student Financial Aid Subrecipient Monitoring Reporting

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the N...

The enrollment reporting issue specifically relates to the integrated BS/PharmD degree program. The University's primary operating system, Jenzabar, reports concurrent enrollment status for P1 students and students who have graduated from the bachelor's degree component of the program. Since the National Student Clearinghouse's (NSC's) system automatically overrides the graduation data in the University's Jenzabar report without notifying the University, a two-step corrective action plan has been initiated. The modified reporting process to improve internal controls consists of the following steps: 1. Upload the initial Jenzabar enrollment reporting into the NSC system which will show full-time enrollment for both the bachelor's degree and the PharmD program; 2. File a second report reflecting the date of completion of the bachelor's degree for all students in the integrated program to remedy the NSC system override of graduation data in the initial Jenzabar report; and 3. Conduct a manual verification of graduation data in the National Student Loan Data System to ensure complete, accurate and timely reporting of graduation information from NSC. The modified reporting process is expected to be fully implemented at the conclusion of the 2023-2024 academic year in conjunction with completion of commencement, which is scheduled to occur in May 2024.

View Audit 398

Finding 87 (2023-001)

Significant Deficiency 2023

The Friendly House of Davenport, Iowa

IA

Subrecipient Monitoring

The Organization has implemented a facility monitoring program that incorporates all of the facility visit requirements as described in the grant agreement.

View Audit 105

Finding 1175571 (2022-009)

Material Weakness 2022

Dewey County

OK

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.317 § 200.318 § 200.327 § 200.84

The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.

View Audit 389361

Finding 1175569 (2022-007)

Material Weakness 2022

Dewey County

OK

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

The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.

View Audit 389361

Finding 1174932 (2022-017)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors...

Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors. Procurement procedures will be updated to clearly define vendor classification and SAM.gov requirements. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174926 (2022-013)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174208 (2022-004)

Material Weakness 2022

DAVIESS COUNTY, MISSOURI

MO

Reporting Subrecipient Monitoring § 200.510

This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.

View Audit 387926

Finding 1173697 (2022-005)

Material Weakness 2022

YWCA Tulsa, Inc.

OK

Allowable Costs / Cost Principles Subrecipient Monitoring

Management's response: When the federal grant award came out at the end of December 2021, we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021. Because of this, once we were able to begin invoicing,...

Management's response: When the federal grant award came out at the end of December 2021, we did not get an approved budget and signed contract for work with the State until the beginning of July 2022 for work that dated back to October 1, 2021. Because of this, once we were able to begin invoicing, we utilized percentage allocations for employee's t ime, knowing that the majority of the employees had been doing work tied to the grant were allocated 100% to the grant and that significant time had been going to building up for the grant. However, it was not possible to go back and get time sheets that were tied to the grant for the majority of 2022 because we simply didn't have a contract in place yet. At the end of 2022, we began to utilize a more structured process for tracking allocations, requiring leadership to review their team member's allocations to grants on a quarterly basis and submit those to our Finance, HR, and Grants Compliance team to review. Because this didn't happen early enough in 2022, we did not have enough backup documentation to support the allocations based on what the audit requested. Views of Responsible Officials and Corrective Action : In 2023, we continued our structured process of time allocation reviews and quarterly approvals by leadership, HR, and Finance, and then in 2024, we launched our fi rst ever time study to also review and ensure time allocations were corresponding correctly with the time being spent on the grants. Name of Contact Person: Name:Julie Davis Title Chief Executive Officer Email: juliedavis@ywcatulsa.org Phone: 918-828-2346 Projected Implementation: The implementation is complete.

View Audit 387410

Finding 1173240 (2022-005)

Material Weakness 2022

New Space Nexus

NM

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties

Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monit...

Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monitored running budget, and the Executive Director will review and approve each report prior to submission to AFRL. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by March 31, 2023.

View Audit 386730

Finding 1172718 (2022-003)

Material Weakness 2022

Northwest Indian College

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control ...

Recommendation: We recommend the College implement a suspension and debarment policy and corresponding procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College currently follows its internal control policies to document verification of vendors who may be listed in SAM for suspension and debarment. The College approved an updated procurement policy effective November 7, 2020, to adhere to Uniform Guidance. The College will strengthen (include) the suspension and debarment section to include a policy specific to Debarment and Suspension. Name of the contact person responsible for corrective action: Reatha Tom, Accounts Payable Specialist, and Clarissa Salhus, Finance Manager Planned completion date for corrective action plan: December 31, 2024

View Audit 385956

Finding 1172717 (2022-009)

Material Weakness 2022

Northwest Indian College

WA

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303 § 200.305

Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be es...

Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be established between Grant PI's and the Accounts Payable department to ensure that subrecipient payments are submitted and paid timely. These workflows will be included in the Accounts Payable procedures. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Finding 1172527 (2022-003)

Material Weakness 2022

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring HUD Housing Programs Material Weakness

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...

During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.

View Audit 385755

Finding 1171698 (2022-015)

Material Weakness 2022

Osage County

OK

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.1 § 200.329 § 200.344

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developi...

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developing a comprehensive SOP to ensure accurate and timely tracking and reporting of federal funds, • improving communication and oversight between all county offices to ensure consistent reporting standards, • and ensuring annual compliance with federal reporting requirements. Our collective goal is to implement the policies and structures that will keep Osage County operating with the highest standard of accountability and excellence. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on federal funds. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners. County Treasurer: The County was under the understanding that once we established we were reporting as revenue loss, we would not have to submit the report annually. The final reporting was submitted prior to deadline.

View Audit 384725

Finding 1171695 (2022-012)

Material Weakness 2022

Osage County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk’s administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to up...

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk’s administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to update procedures and build stronger internal controls, • developing and formalizing policies to ensure full compliance with federal grant requirements, • and improving communication between offices to ensure federal reporting is accurate and timely. Our collective commitment is to put permanent measures in place to prevent these issues from recurring and to uphold the highest level of compliance for all federal programs. County Clerk: I was not the County Clerk in office at this time. The County will comply with all aspects of grant reporting and requirements. The Officials will work together to put policies and procedures in place to ensure more accurate reporting. County Treasurer: The County Officers will work on better communication to more accurately report the SEFA funds.

View Audit 384725

Finding 1171694 (2022-011)

Material Weakness 2022

Osage County

OK

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior Clerk’s administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County...

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior Clerk’s administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County Commissioners, the new County Clerk and the other elected officials have made addressing these control weaknesses a priority. Together, we are: • strengthening county-wide policies and procedures to meet federal compliance requirements • improving communication and oversight to ensure accurate and timely federal reporting • and establishing clear standards and training for all reporting officers to prevent inaccurate or untimely reporting. Our collective goal is to build a stronger, more accountable system that ensures federal programs are managed with the highest level of integrity. County Clerk: I was not the County Clerk in office at this time. Ensure that the County has standards in place that will deter inaccurate and untimely reporting. In addition, those reporting have the knowledge and understanding to properly report. County Treasurer: The County Officers will work on better communication to more accurately report the Schedule of Expenditures of Federal Awards (SEFA) funds.

View Audit 384725

Finding 1170706 (2022-011)

Material Weakness 2022

Hope the Mission

CA

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.510

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Managem...

The Schedule of Expenditures of Federal Awards (SEFA) provided to the audit firm was incomplete due to two primary factors: (1) insufficient understanding by staff regarding the requirement to include federally funded capital expenditures, and (2) improper recording of property acquisitions. Management acknowledges this oversight, which occurred during the implementation of a new program and at a time when staff were not fully aware that such expenditures must be reflected on the SEFA. Furthermore, certain capital expenditures paid directly through escrow were not recorded in the organization's accounting records. To remediate these issues, management has taken the following corrective actions: - Delivered targeted training to staff on the proper treatment and reporting of federally funded capital expenditures; - Updated internal closing and reporting procedures to incorporate a formal review of balance sheet activity; and - Updated internal closing and reporting procedures to incorporate a reconciliation to settlement statements when recording new property acquisitions; and - Strengthened internal controls to ensure all federally funded capital items are accurately captured in future SEFA submissions. Management is committed to maintaining compliance with federal reporting requirements and ensuring the completeness and accuracy of future SEFA filings.

View Audit 383904

Finding 1170700 (2022-010)

Material Weakness 2022

Hope the Mission

CA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.319 § 200.320

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement stand...

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement standards. We have implemented a formal procurement policy, created a dedicated Procurement sub-department within Finance, hired a Procurement Supervisor and support team, and launched a new procurement software platform to ensure proper solicitation, documentation, approval routing, and record retention for all Federally funded programs. These upgrades establish consistent competitive bidding, justification procedures, conflict-of-interest safeguards, and transparent procurement. In addition, we have strengthened oversight, provided staff training on Federal procurement standards, and embedded monitoring practices to ensure ongoing compliance. Management is confident these substantial structural improvements have significantly reduced the risk of noncompliance and positioned the organization for full alignment with federal procurement standards going forward.

View Audit 383904

Finding 1170692 (2022-009)

Material Weakness 2022

Hope the Mission

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302 § 200.403

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken sign...

Management acknowledges this finding and agrees that during the period under audit-while the organization was experiencing rapid growth and increased program activity-our documentation and approval processes did not consistently keep pace with operational demands. Since that time, we have taken significant steps to strengthen accounting procedures and internal controls, reinforce our invoice approval policies, and ensure all expenditures charged to Federal awards are properly reviewed and authorized prior to processing. We have enhanced our Accounts Payable workflow by implementing standardized process approval requirements, added additional leadership staffing and oversight within the Finance and Accounting team and provided targeted training to all personnel involved in invoice processing to ensure understanding of Federal cost principles and documentation standards. These corrective actions have improved our control environment since the audit period, and management is committed to continuing to develop and maintain strong financial controls and to prevent recurrence of this issue.

View Audit 383904

Finding 1170423 (2022-002)

Material Weakness 2022

Baltimore Medical System, Inc.

MD

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.510

Finding: During the audit of the auditee's SEFA for the year ended December 31, 2022, we noted discrepancies related to incorrect identification of Assistance Listing Numbers for certain grants, as well as difficulty providing initial supporting detail for balances of expenditures for certain Federa...

Finding: During the audit of the auditee's SEFA for the year ended December 31, 2022, we noted discrepancies related to incorrect identification of Assistance Listing Numbers for certain grants, as well as difficulty providing initial supporting detail for balances of expenditures for certain Federal programs. The auditee lacks sufficient internal controls over the preparation and review of the SEFA. Specifically, there is no established process to reconcile federal expenditures reported on the SEFA to the auditee's underlying accounting records. A formal review process involving an individual independent of the preparation was not conducted to ensure the SEFA was complete and accurate before submission to the auditors. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to establish and document a formal, multilevel review process for the preparation of the SEFA. Baltimore Medical System recently hired a new grant accountant who will be responsible for the preparation of the SEFA. • The Controller will perform a detailed reconciliation of the SEFA’s data to the general ledger and supporting grant documents. • The Grant Accountant will develop a central repository that includes all grant contracts/awards and a summary document which contains the grant name, grantee, award amount and period, Assistance Listing Numbers, pass-through entity and subrecipient information. • Train relevant staff on the SEFA requirements governed by the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for the Federal Awards (2 CFR Part 200, 200.510(b)). Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO

View Audit 383596

Finding 1169020 (2022-007)

Material Weakness 2022

City of Hollister

CA

Subrecipient Monitoring Matching / Level of Effort / Earmarking

The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans...

The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans and collection of required annual documentation. Staff will receive refresher training on HOME requirements.

View Audit 381688

Finding 1168941 (2022-001)

Material Weakness 2022

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 381458

Corrective Action Plans

Filters