Corrective Action Plans

Finding 560539 (2023-003)

Material Weakness 2023

Elverado Community Unit School District

CO

Internal Control / Segregation of Duties

The District will segregate duties to the best of its ability and ensure proper oversight by management.

View Audit 356444

Finding 560538 (2023-002)

Material Weakness 2023

Elverado Community Unit School District

CO

Internal Control / Segregation of Duties

The District will implement internal controls procedures and consider hiring a trained individual to ensure complete and accurate financial statements.

View Audit 356444

Finding 560537 (2023-001)

Material Weakness 2023

Elverado Community Unit School District

CO

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The District will establish policies and procedures to be followed to ensure proper review, approval and recording of federal expenditures.

View Audit 356444

Finding 560487 (2023-001)

Significant Deficiency 2023

Town of Sturbridge, Massachusetts

MA

Questioned Costs Allowable Costs / Cost Principles

Department of Education Finding 2023-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of ...

Department of Education Finding 2023-001 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Program Condition: During our test of controls over compliance it was noted that an employee’s payroll charged to the Education Stabilization Fund – ESSER III major program was for services that was not included as part of the grant application/budget. Criteria: Costs charged to the major program should meet the requirements as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Context: During our review of the payroll charged to the major program it was noted that one of the employees charged to the grant was for stipend pay for work as a ELL Coordinator that was charged to the Salaries budget of the grant, which does not support the services charged. Thus the payroll expense would be unallowable. Effect: Town of Sturbridge was not in compliance with the allowable costs/ cost principals requirement as set forth by the Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Questioned Costs: $862.50 Cause: The stipend for the ELL Coordinator was considered salary by the school department. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Sturbridge follow procedures to ensure that payroll expenditures charged to the grant is allowable costs as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles) Responsible for Corrective Plan: Director of Business and Finance Estimated Completion Date: October 2024 Action Taken: Moving forward the school department bookkeepers will work to ensure expenditures are properly established, funded and within allowable cost guidelines.

View Audit 356376 Questioned Costs: $1

Finding 560486 (2023-002)

Material Weakness 2023

Town of Sturbridge, Massachusetts

MA

Material Weakness Internal Control / Segregation of Duties

Finding 2022-002 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Criteria: Wh...

Finding 2022-002 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the school department provided time and effort certifications that did not agree to the payroll records, and were not dated at the time of approval. Questioned Costs: Unknown Context: During our test of payroll transactions of the ESSER II and ESSER III grants it was noted that the time and effort certifications did not agree to the payroll records and were not dated. Effect: The Town of Sturbridge was not in compliance with the time and effort certification requirements. Cause: Due to staffing changes, time and effort documents were not completed in a timely manner. Identification as a Repeat Finding: N/A Recommendation: We recommend the Town of Sturbridge follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and agree with the payroll records, and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Director of Business and Finance Estimated Completion Date: October 2024 Action Taken: Moving forward the school department bookkeepers will work to ensure time and effort certifications are completely in a timely fashion.

View Audit 356376

Finding 560441 (2023-001)

Material Weakness 2023

Okanogan County Public Heath

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding caption: The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Jill Gates Fiscal Coordinator 1234 2nd Ave South Okanogan, WA 98840 (509) 422-7140 Corrective ac...

Finding caption: The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Jill Gates Fiscal Coordinator 1234 2nd Ave South Okanogan, WA 98840 (509) 422-7140 Corrective action the auditee plans to take in response to the finding: The District has a Board of Health approved Procurement Policy in place and has followed it since the release of the 2022 Audit Report which was issued September 20, 2023. The District added a suspension and debarment provision to all agreements that include a federal funding component, while still checking the status on Sam.gov. The District also went back and reviewed previous agreements to ensure the entities providing services to the District were not suspended or debarred (none were suspended or debarred). These changes went into effect immediately following the finding issued to the District in September 2023 (resulting from the 2022 Audit Finding). From January 2023-September 2023 the District was unaware of the corrective action necessary due to the timing of the 2022 Audit Report. Therefore, during 2023, this finding was partially corrected and has since been fully corrected. Anticipated date to complete the corrective action: 12/2024

View Audit 356347

Finding 560439 (2023-002)

Significant Deficiency 2023

Kentucky Refugee Ministries, Inc.

KY

Significant Deficiency

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Audit Clearinghouse. Action Taken: KRM continues to take steps to increase the staffing to help with the increased number of refugees served as well as implementing new software changes to streamline ...

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Audit Clearinghouse. Action Taken: KRM continues to take steps to increase the staffing to help with the increased number of refugees served as well as implementing new software changes to streamline processes for more efficient operations.

View Audit 356342

Finding 560432 (2023-002)

Material Weakness 2023

The Center for Black Women's Wellness, Inc.

GA

Procurement, Suspension & Debarment § 200.303

Recommendation: We recommend the Organization strengthen its policies and procedures to ensure procurement and suspension and debarment is adequately documented for that goods and services purchased in accordance with Uniform Guidance and other federal guidelines. In addition, the Organization shoul...

Recommendation: We recommend the Organization strengthen its policies and procedures to ensure procurement and suspension and debarment is adequately documented for that goods and services purchased in accordance with Uniform Guidance and other federal guidelines. In addition, the Organization should verify that all vendors under covered transactions are not listed on the excluded parties list system by performing a search on sam.gov and maintaining the results of such search in the vendor’s file. Grantee Response and Corrective Action Plan 2023-002: In response to the audit finding under 2 CFR part 180 regarding the necessity to verify suspension or debarment status in compliance with the excluded parties list system, it is acknowledged that while the Center for Black Women’s Wellness did not previously have a formal policy specifically addressing suspension and debarment, our practices have nonetheless complied with the requirements. Recognizing the importance of formalizing these practices into policy, we are committed to developing and implementing a comprehensive policy that explicitly addresses these checks. This initiative will be integrated with our existing compliance frameworks to ensure consistent adherence across all procurement activities. In line with our recent enhancements in internal controls, including the engagement of a Contractual CFO in 2024, this policy will reinforce our ongoing efforts to uphold the highest standards of compliance and accountability in all our operations. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 356331

Finding 560431 (2023-001)

Material Weakness 2023

The Center for Black Women's Wellness, Inc.

GA

Cash Management Internal Control / Segregation of Duties § 200.303 § 200.305

Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2023-001: We concur...

Recommendation: We recommend that internal controls be strengthened and processes implemented to ensure all draw down requests are reviewed and approved to ensure costs were accurately reported and paid before requesting reimbursement. Grantee Response and Corrective Action Plan 2023-001: We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. Previously draw down documentation was uploaded to a shared folder, in which the CEO and Fiscal Manager had access. In 2024, we implemented additional procedures to document review of drawdowns and supporting documentation. Additionally, documentation includes attaining the CEO signature on draw down documentation before the draw down is made. Responsible Parties: Jemea Dorsey, CEO Date Corrected: April 30, 2024

View Audit 356331

Finding 560406 (2023-003)

Significant Deficiency 2023

The Pines Housing, Inc.

OR

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Finding Reference Number: 2023-003 Condition: In September 2023, HUD suspended its HAP subsidy to the Organization due to noncompliance regarding the tenant recertifications requirements under the HAP Contract. Recommendation: We recommend that control systems are put in place to ensure there are re...

Finding Reference Number: 2023-003 Condition: In September 2023, HUD suspended its HAP subsidy to the Organization due to noncompliance regarding the tenant recertifications requirements under the HAP Contract. Recommendation: We recommend that control systems are put in place to ensure there are regular reviews of tenant files to enable management to identify deficiencies and provide training, guidance, and procedures to eliminate errors and issues of noncompliance in the future. Reporting views of responsible officials Our Just Future, on behalf of The Pines Housing, Inc., both concurs with these findings and agrees with auditor recommendations. Completion date or proposed completion date: December 18, 2024 Action(s) taken or planned on the finding OJF has completed all overdue tenant recertifications. To prevent future delinquent recertifications, OJF will conduct a root cause analysis by January 15, 2025 to identify gaps in the current process. Once gaps are identified, procedures will be updated to provide clear guidelines and timelines to staff. By February 15, 2025, OJF will implement a tracking system for tenant recertifications, including supervisory review of all tenant files. By March 15, 2025, relevant OJF staff will undergo training on compliance with HUD requirements. This will include the creation of a compliance calendar. OJF’s senior management team and board of directors will monitor progress towards these goals. Progress reports will be drafted no later than April 15, 2024

View Audit 356309

Finding 560404 (2023-002)

Significant Deficiency 2023

The Pines Housing, Inc.

OR

Eligibility HUD Housing Programs Reporting

Finding Reference Number: 2023-002 Condition: As of December 12, 2024, management was unable to provide tenant income documents for 2 tenant files of 7 tenant files sampled out of the population (66 total tenant files). Management was unable to provide tenant security deposit documents for all 3 mov...

Finding Reference Number: 2023-002 Condition: As of December 12, 2024, management was unable to provide tenant income documents for 2 tenant files of 7 tenant files sampled out of the population (66 total tenant files). Management was unable to provide tenant security deposit documents for all 3 move-ins and move-outs sampled out of the population (9 total move-ins and 13 total move-outs during the audit period). Recommendation: We recommend that control systems are put in place to ensure there are regular reviews of tenant files to enable management to identify deficiencies and provide training, guidance, and procedures to eliminate errors and issues of noncompliance in the future. Reporting views of responsible officials Our Just Future, on behalf of The Pines Housing, Inc., both concurs with these findings and agrees with auditor recommendations. Completion date or proposed completion date: December 18, 2024 Action(s) taken or planned on the finding To address this finding, OJF will take the following actions: 1. Implement regular tenant file reviews at least semi-annually beginning January 15, 2025 a. Responsible party: OJF asset management director and property management portfolio manager 2. Develop a mandatory training program on compliance requirements for property management site staff to follow by February 15, 2025 a. Responsible party: OJF asset management director and property management portfolio manager 3. Revise and distribute existing tenant file management procedures by February 15, 2025 a. Responsible party: OJF asset management director and property management portfolio manager 4. Establish a monitoring and feedback system by March 15, 2025 for site staff to seek guidance on or report challenges of file management so that advice can be given and/or corrective action taken a. Responsible party: OJF asset management director and property management portfolio manager 5. Conduct quarterly management reviews beginning 4/15/2025 to discuss and evaluate the effectiveness of above actions a. Responsible party: OJF asset management director and property management portfolio manager

View Audit 356309

Finding 560393 (2023-004)

Material Weakness 2023

Bakersfield, American Indian Health Project INC

CA

Reporting Internal Control / Segregation of Duties

Establish and Maintain a Reporting Calendar: A comprehensive grant reporting calendar will be implemented to track all financial and performance reporting deadlines. Calendar will include due dates, responsible staff, and required supporting documentation. Assigned Clear Roles and Responsibilities:...

Establish and Maintain a Reporting Calendar: A comprehensive grant reporting calendar will be implemented to track all financial and performance reporting deadlines. Calendar will include due dates, responsible staff, and required supporting documentation. Assigned Clear Roles and Responsibilities: Each grant report will have a designated preparer and reviewer. The Controller will be responsible for ensuring that all reports reconcile to the general ledger before submission. Implemented Standardized Reporting Procedures: A written Grants Reporting and Procedure Manual will be developed outining step-by-step procedures for preparing, reviewing, and submitting reports. Reports will only be submitted after reconciliation with the accounting system and documented approval from the Finance Director or Controller. Training and Capacity Building: Staff responsible for grant reporting will receive annual training on federal compliance requirements, Uniform Guidance, and internal procedures. Training sessions will include examples of common reporting errors and reconciliation best practices. Monitoring and Internal Reviews: The Finance Director will conduct a monthly compliance check to verify timely completion and accuracy of each report. Quarterly internal audits will be conducted to assess adherence to the reporting procedures and controls.

View Audit 356287

Finding 560390 (2023-003)

Material Weakness 2023

Bakersfield, American Indian Health Project INC

CA

Reporting Internal Control / Segregation of Duties

Reporting Calendar and Schedule: A grant reporting calendar will be created and maintained, outlining all required reporting deadlines for each funding source, including due dates, responsible staff, and required documentation. The calendar will be reviewed weekly by the Finance Director to ensure u...

Reporting Calendar and Schedule: A grant reporting calendar will be created and maintained, outlining all required reporting deadlines for each funding source, including due dates, responsible staff, and required documentation. The calendar will be reviewed weekly by the Finance Director to ensure upcoming deadlines are met. Assignment of Responsibilities: Clear responsibilities will be assigned to specific personnel for each step of the reporting process, including data preparation, report drafting, internal review, and final submission. A checklist will be used for each report to document the review proceduress and ensure all elements are completed accurately and timely. Reconciliation Procedures: All reports will be reconciled to the general ledger and supporting schedules prior to submission to ensure consistency and accuracy. Supporting documentation will be attached to each report file to provide an audit trail. Internal Review Process: A second-level review by the Controller or Finance Director will be required before reports are submitted to funding agencies. Review will include verifying accuracy, completeness, and agreement with accounting system data. Training and Internal Controls: Staff responsible for report preparation will undergo annual training on grant compliance requirements, Uniform Guidance, and reporting accuracy. Internal controls will be documented in Grants Management Policy and Procedures Manual, including reporting guidelines. Monitoring and Follow-Up: Compliance with the reporting calendar and procedures will be tracked monthly. Any missed or delayed reports will be investigated, and corrective actions taken immediately.

View Audit 356287

Finding 560385 (2023-002)

Significant Deficiency 2023

Public Housing Authority of Butte

MT

HUD Housing Programs Eligibility Reporting

The Public Housing Authority of Butte will contract with the Certified Public Accounting firm to assist with timely submission of the FY 2024 unaudited Financial Data Schedule. This will provide su icient time for the audit to get completed by the audited FASSPHA deadline.

View Audit 356277

Finding 560353 (2023-003)

Material Weakness 2023

Cornerstone Whole Healthcare Organization, Inc.

ID

Questioned Costs Cash Management Material Weakness

Plan of Action: A New Cash Management Procedure was implemented on 5/5/24. We have also developed a tracking system in Microsoft Forms for the Project Director or Authorizing Officer to request and approve funds.

View Audit 356257 Questioned Costs: $1

Finding 560348 (2023-002)

Material Weakness 2023

Cornerstone Whole Healthcare Organization, Inc.

ID

Reporting Material Weakness § 200.328

Plan of Action: To correct deficiencies in the preparation and submission of the SF-425 Federal Financial Report, the organization has established SOP F1.03: Submission and Recordkeeping of Federal Financial Reports (SF-425). This procedure outlines the steps for accurately completing the SF-425 usi...

Plan of Action: To correct deficiencies in the preparation and submission of the SF-425 Federal Financial Report, the organization has established SOP F1.03: Submission and Recordkeeping of Federal Financial Reports (SF-425). This procedure outlines the steps for accurately completing the SF-425 using verified financial data, submitting it through the appropriate federal systems by required deadlines, and maintaining supporting documentation in compliance with federal recordkeeping standards. It applies to all staff involved in financial reporting on federally funded grants.

View Audit 356257

Finding 560343 (2023-001)

Material Weakness 2023

Cornerstone Whole Healthcare Organization, Inc.

ID

Procurement, Suspension & Debarment § 200.318 § 200.326

Plan of Action: Provided policy F2.0 Materials Management, F2.01 Vendor Selection & Discount – currently being reviewed with the board for updates, and F2.03 Inventory and Supplies, which were not provided to the auditor due to the organization’s operational error in financial policy classification....

Plan of Action: Provided policy F2.0 Materials Management, F2.01 Vendor Selection & Discount – currently being reviewed with the board for updates, and F2.03 Inventory and Supplies, which were not provided to the auditor due to the organization’s operational error in financial policy classification. Additionally, the F2.02 Capital and Equipment policy was drafted in 2021 will be reviewed and signed by the organizational board on Aug 26, 2024. The organization acknowledges that the procurement policy was not followed for one vendor procurement in 2022 due to an administrative error. This policy will be implemented and strictly followed immediately.

View Audit 356257

Finding 560342 (2023-001)

Significant Deficiency 2023

Healthy Relationships California

CA

§ 200.512

Healthy Relationships California management will ensure the audit is completed within the required time period and submitted to the Federal Audit Clearinghouse promptly in conjunction with the external accounting firm.

View Audit 356255

Finding 560337 (2023-002)

None 2023

Near West Side Multi-Service Corporation

OH

Internal Control / Segregation of Duties

We will implement a comprehensive review process to ensure all required documentation is included. This will involve regular audits of case files, enhanced training for staff on documentation requirements, and the development of a standardized checklist to ensure completeness.

View Audit 356241

Finding 560336 (2023-001)

None 2023

Near West Side Multi-Service Corporation

OH

Reporting Internal Control / Segregation of Duties

We will implement stricter adherence to deadlines and ensure that all reports are filed on time. Measures will include setting up reminder systems and providing additional training to staff on the importance of meeting these deadlines.

View Audit 356241

Finding 560335 (2023-004)

None 2023

City of Dunkirk, New York

NY

Reporting

View of Responsible Officials and Planned Corrective Action Plan—The City will update amounts and descriptions within the Department of Treasury’s reporting portal to ensure all amounts expended are properly reported.

View Audit 356234

Finding 560313 (2023-002)

Material Weakness 2023

Springboard Collaborative

PA

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Issue Corrective Actions Responsible Party Status Springboard Collaborative did not maintain adequate time and effort reports for staff salaries and fringe benefits for all employees who spent less than 100% of their time working on this major program. Implement quarterly effort report certification...

Issue Corrective Actions Responsible Party Status Springboard Collaborative did not maintain adequate time and effort reports for staff salaries and fringe benefits for all employees who spent less than 100% of their time working on this major program. Implement quarterly effort report certification process, which requires eligible employees, their managers, and the grant management staff to review and certify effort charged to grant funding during the applicable reporting period. **The effort report certification process was fully enabled and completed in response to Single Audit review during the FY23 audit process and in preparation for FY24 audit. Grant management staff (Associate Director, Fiscal Grant Management) Completed Corrective Action

View Audit 356226 Questioned Costs: $1

Finding 560310 (2023-003)

Material Weakness 2023

Windsor Housing Authority

CT

HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2023-003- REPORTING Material Weakness/Noncompliance Auditee’s Response and Planned Corrective Action WHA will develop written accounting policies and a deliverables calendar to eliminate late submissions moving forward. We will incorporate this into training for all staff and work with the fee accou...

2023-003- REPORTING Material Weakness/Noncompliance Auditee’s Response and Planned Corrective Action WHA will develop written accounting policies and a deliverables calendar to eliminate late submissions moving forward. We will incorporate this into training for all staff and work with the fee accountant and Auditors to make sure deadlines are realistic, coordinated and attainable. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Maria DeMarco, President of DeMarco Management Corporation

View Audit 356224

Finding 560309 (2023-002)

Material Weakness 2023

Windsor Housing Authority

CT

HUD Housing Programs Subrecipient Monitoring Eligibility

2023-002- ELIGIBILITY Material Weakness/Noncompliance Auditee’s Response and Planned Corrective Action We follow HUD guidelines where required and Untimely recertifications are typically not within the control of the Housing Authority. Encompassing HUD guidelines, the recertification process for ten...

2023-002- ELIGIBILITY Material Weakness/Noncompliance Auditee’s Response and Planned Corrective Action We follow HUD guidelines where required and Untimely recertifications are typically not within the control of the Housing Authority. Encompassing HUD guidelines, the recertification process for tenants begins 90 days prior to the recert date, but if tenants do not provide all the requested information, the recertification will be delayed until the information is provided, tenant is converted to a market rate rent, or we begin the termination process for termination of the voucher. We will continue to follow the HUD process for the management of the Housing Choice Voucher Programs/Mainstream voucher programs. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Maria DeMarco, President of DeMarco Management Corporation

View Audit 356224

Finding 560269 (2023-002)

Material Weakness 2023

Benton Franklin Community Action Committee

WA

Questioned Costs Allowable Costs / Cost Principles

BFCAC made a change in personnel during 2024. Subsequently BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for this...

BFCAC made a change in personnel during 2024. Subsequently BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for this corrective action.

View Audit 356210 Questioned Costs: $1

Corrective Action Plans

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