Corrective Action Plans

Finding 500429 (2023-005)

Significant Deficiency 2023

Meeker County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sa...

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 323197

Finding 500426 (2023-004)

Significant Deficiency 2023

Meeker County

MN

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in ...

REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

View Audit 323197

Finding 500425 (2023-004)

Significant Deficiency 2023

Fargo Housing and Redevelopment Authority

ND

Eligibility HUD Housing Programs Significant Deficiency

Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CA...

Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2024

View Audit 323194

Finding 500424 (2023-001)

Significant Deficiency 2023

Housing Authority of the City of Sheboygan

WI

Questioned Costs Eligibility HUD Housing Programs

The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.

View Audit 323183 Questioned Costs: $1

Finding 500422 (2023-001)

Significant Deficiency 2023

County of Wayne, New York

NY

Questioned Costs Eligibility

The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.

View Audit 323181 Questioned Costs: $1

Finding 500420 (2023-004)

None 2023

St. Francis Village, Inc.

TX

Questioned Costs Procurement, Suspension & Debarment

Finding 2023-004: Federal Procurement Requirements for Policies and Documentation a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities in response to a formal Request for Proposal are consistent with current federal requireme...

Finding 2023-004: Federal Procurement Requirements for Policies and Documentation a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities in response to a formal Request for Proposal are consistent with current federal requirements and specifically with the regard to ensuring that proper documentation and records are maintained in sufficient detail to support the history of each procurement transaction by having three competitive bids and retaining the bids in the procurement file. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately. c. Person Responsible for Corrective Action: Executive Director in conjunction with the Board of Directors.

View Audit 323177 Questioned Costs: $1

Finding 500419 (2023-003)

None 2023

St. Francis Village, Inc.

TX

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs § 200.213

Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensurin...

Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensuring contractual parties are not disbarred. This is to ensure compliance with HUD entering into contracts with vendors who are disbarred or suspended from participation in federal programs. Maintain documentation in each vendor file to verify selected vendors are not disbarred or suspended. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately to ensure proper documentation is in place for selected vendors. c. Person Responsible for Corrective Action: Executive Director

View Audit 323177 Questioned Costs: $1

Finding 500418 (2023-002)

Material Weakness 2023

St. Francis Village, Inc.

TX

Internal Control / Segregation of Duties

Finding 2023-002: Executive Director has both signature authority and direct access to financial recording. a. Responsible Official’s Response: Management will modify its internal control practices to ensure proper segregation of duties as soon as reasonably practicable and upon the hiring of a Con...

Finding 2023-002: Executive Director has both signature authority and direct access to financial recording. a. Responsible Official’s Response: Management will modify its internal control practices to ensure proper segregation of duties as soon as reasonably practicable and upon the hiring of a Controller which will allow access to the financial accounting system by the Business Manager and the Controller and restricting the Executive Director’s access to “view only.” Additionally, management will evaluate the implementation of an electronic payables system and a positive pay system with its banks to its enhance segregation of duties. b. Planned Implementation Date of Corrective Action: Management will implementation this change immediately upon the hiring of a Controller as soon as reasonably practicable, with a target date the end of October 2024.. c. Person Responsible for Corrective Action: Executive Director with advice from the Board of Directors.

View Audit 323177

Finding 500417 (2023-001)

Material Weakness 2023

St. Francis Village, Inc.

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Finding 2023-001: Adjustments, both individually and in aggregate were material to the financial statements. Adjustments were needed to correct cash, accounts receivable, fixed assets, accounts payable, accrued expense, and debt balances. Several key review processes were not occurring. a. Responsib...

Finding 2023-001: Adjustments, both individually and in aggregate were material to the financial statements. Adjustments were needed to correct cash, accounts receivable, fixed assets, accounts payable, accrued expense, and debt balances. Several key review processes were not occurring. a. Responsible Official’s Response: Management will modify its internal control practices to ensure that proper daily and monthly accounting processes and procedures are being followed for all asset and liability accounts by the Business Manager and reviewed timely each month by the Executive Director. Management is in the process of hiring a Controller to assist with monthly accounting cycle, reconciliations, and financial statement reporting, allowing the Executive Director to have more oversight responsibilities for the financial statements as a whole. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately. c. Person Responsible for Corrective Action: Executive Director in conjunction with advice from the Board of Directors.

View Audit 323177

Finding 500405 (2023-003)

Significant Deficiency 2023

Town of Paoli

IN

Reporting Subrecipient Monitoring Significant Deficiency § 200.328

Management of the Town will work to adopt a formal federal reporting policy and monitoring system that will ensure accurate and timely reporting of all grants. The Town will also assign a reporting leader to become familiar with all reporting requirements and monitor the timeline of the reporting r...

Management of the Town will work to adopt a formal federal reporting policy and monitoring system that will ensure accurate and timely reporting of all grants. The Town will also assign a reporting leader to become familiar with all reporting requirements and monitor the timeline of the reporting requirements.

View Audit 323172

Finding 500404 (2023-002)

Material Weakness 2023

Town of Paoli

IN

Procurement, Suspension & Debarment § 200.303 § 200.317 § 200.318 § 200.319 § 200.320

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the ...

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the Town's new procurement policy is followed.

View Audit 323172

Finding 500403 (2023-002)

Material Weakness 2023

West Virginia University Health System and Controlled Entities

WV

Internal Control / Segregation of Duties Eligibility Material Weakness

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be ta...

Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024

View Audit 323168

Finding 500402 (2023-001)

Significant Deficiency 2023

West Virginia University Health System and Controlled Entities

WV

Reporting Significant Deficiency Internal Control / Segregation of Duties

Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management di...

Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management did not identify the earlier required monthly reporting deadline as part of the renewal and continued to submit monthly grant reports following the former reporting timeline which caused the monthly reports to be submitted late for the months of October 2023 through March 2024. Management identified the discrepancy and began submitting the monthly reporting timely with reporting for April. Going forward Management reviews the reporting timely requirements of all new grant agreements and grant agreement renewals to ensure required monthly reporting deadlines are met. Completion Date: 04/15/2024

View Audit 323168

Finding 500401 (2023-001)

None 2023

Riderwood Village, Inc. and Subsidiary

MD

Reporting Equipment & Real Property Management

The Management of Riderwood Village, Inc. and its subsidiary prioritize implementing and maintaining effective internal controls, particularly with respect to funds received from the Federal government. Through ongoing communication, training, and consistent policy enforcement, Management has contin...

The Management of Riderwood Village, Inc. and its subsidiary prioritize implementing and maintaining effective internal controls, particularly with respect to funds received from the Federal government. Through ongoing communication, training, and consistent policy enforcement, Management has continued to promote sound business practices and strong internal controls throughout Riderwood Village, Inc. and its subsidiary. The following outlines Management’s Views and Corrective Action Plan concerning the Schedule of Findings and Questioned Costs for the year ended December 31, 2023. Finding 2023-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (“HHS”) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – Period 5 Award Year(s): January 1, 2020 – December 31, 2023 Management acknowledges the issue identified in the audit. Based on the email evidence provided, Management confirms that all proper authorizations were obtained, and the disbursement of the stay bonus to employees were deemed allowable. Prospectively, Management remains committed to ensuring the accuracy and compliance of all disbursements under the Provider Relief Fund and ARP Rural Distribution programs.

View Audit 323164

Finding 500400 (2023-002)

Significant Deficiency 2023

The Tule Basin Land and Water Conservation Trust

CA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.

View Audit 323160 Questioned Costs: $1

Finding 500399 (2023-001)

Significant Deficiency 2023

The Tule Basin Land and Water Conservation Trust

CA

Questioned Costs Procurement, Suspension & Debarment § 200.320

Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the ...

Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the Tule Trust Finance Committee to prevent duplication and to ensure that costs are reasonable.

View Audit 323160 Questioned Costs: $1

Finding 500396 (2023-005)

Material Weakness 2023

City of Greeley

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 202...

Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500393 (2023-004)

Material Weakness 2023

City of Greeley

CO

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness

Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to e...

Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to ensure prior to entering into an agreement with an outside entity using federal funds, the City will perform the suspension and debarment check. Documentation of this review will be retained with the grant documents. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500392 (2023-003)

Material Weakness 2023

City of Greeley

CO

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establ...

Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024

View Audit 323158

Finding 500390 (2023-001)

Material Weakness 2023

Northwest Youth Services

WA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Divi...

Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024

View Audit 323157 Questioned Costs: $1

Finding 500387 (2023-002)

Significant Deficiency 2023

The New Mexico Farmers Marketing Association

NM

Reporting

View of Responsible Official The Executive Director will take action to make sure USDA reports are filed on time. The ED will work with the Finance Director to ensure deadlines are met. Timeline This will be implemented as of 9/27/2024 Staff Responsible Executive Director

View Audit 323155

Finding 500386 (2023-002)

Material Weakness 2023

Jackson County, Colorado

CO

Reporting Internal Control / Segregation of Duties § 200.100 § 200.510

Material Weakness, Inaccurate Schedule of Expenditures Of Federal Awards (The SEFA) Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its ...

Material Weakness, Inaccurate Schedule of Expenditures Of Federal Awards (The SEFA) Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls by implementing additional training and oversight of personnel to ensure the SEFA accurately reflects all federal expenditures for the fiscal year properly. The County is in the process of implementing an accounting software package with a corresponding month and year-end closing process to ensure balances are reconciled and reviewed.

View Audit 323150

Finding 500385 (2023-003)

Material Weakness 2023

Jackson County, Colorado

CO

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s rec...

Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant allowable costs and activities determinations and reporting requirements and will implement a process that ensures federal expenditure accounting and reports are prepared and then reviewed and approved by a separate employee prior to submission.

View Audit 323150

Finding 500384 (2023-001)

Material Weakness 2023

Whatley Health Services, Inc.

AL

Subrecipient Monitoring Program Income

2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corpor...

2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corporation has conducted several staff trainings and has revised its review procedures for checking compliance to improve monitoring of the process by the Corporation. Completion Date: Estimated December 2024. Contact Person: Rajuan Sherman - Chief Financial Officer - 2731 M.L. King, Jr. Blvd, Tuscaloosa, AL 35403 - (205) 614-6070 - rsherman@whatleyhealth.org.

View Audit 323140

Finding 500374 (2023-005)

Significant Deficiency 2023

Milton Housing Authority

MA

Allowable Costs / Cost Principles

Finding No. 2023-005 -Allowable Costs/Cost Principles; Significant Deficiency (#14.896 - Family Self Sufficiency Program) Auditee's Response and Planned Corrective Action The Milton Housing Authority will review FSS program guidelines and reimbursable activities to ensure that it is properly disburs...

Finding No. 2023-005 -Allowable Costs/Cost Principles; Significant Deficiency (#14.896 - Family Self Sufficiency Program) Auditee's Response and Planned Corrective Action The Milton Housing Authority will review FSS program guidelines and reimbursable activities to ensure that it is properly disbursing FSS Funds. To that end, MHA is working closely with HUD officials. Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169

View Audit 323134

Corrective Action Plans

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