Corrective Action Plans

Finding 500108 (2023-001)

Material Weakness 2023

CT

HUD Housing Programs Eligibility

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: The Enterprise Income Verification (EIV) form in the existing tenant's file for 5 out of 15 tenants tested did not have the EIV...

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In connection with out lease file review, we noted the following deficiencies: The Enterprise Income Verification (EIV) form in the existing tenant's file for 5 out of 15 tenants tested did not have the EIV completed within 120 days, as required by HUD. The Enterprise Income Verification (EIV) form in the existing tenant's file for 1 out of 15 tenants tested did not have documentation in their lease file that their income was verified. The Enterprise Income Verification (EIV) form in the new tenant's file for 1 out of 2 tenants tested did not have documentation in their lease file that their income was verified. b. Action(s) Taken or Planned on the Finding Management has implemented a monthly compliance file audit that will ensure that EIV’s are pulled and tenant income verified in a timely manner.

View Audit 322943

Finding 500107 (2023-004)

Material Weakness 2023

Shiloh Manor, Inc.

CT

Questioned Costs HUD Housing Programs Eligibility

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid real estate tax expenses in the amount of $9,400 from project cash while a tax abatement agreement was in effect. b. Action(s) Taken or Planned on the Finding Management contacted City of Middleto...

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid real estate tax expenses in the amount of $9,400 from project cash while a tax abatement agreement was in effect. b. Action(s) Taken or Planned on the Finding Management contacted City of Middletown Tax Assessor who has agreed to reverse the bill. Management is working with the assessor to get the funds reimbursed.

View Audit 322940 Questioned Costs: $1

Finding 500106 (2023-003)

Significant Deficiency 2023

Shiloh Manor, Inc.

CT

HUD Housing Programs

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project did not make the required monthly deposits to the replacement reserve in the amount of $66,000 as $5,500 was not made timely. The project is required to make timely monthly deposits to the reserve in t...

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project did not make the required monthly deposits to the replacement reserve in the amount of $66,000 as $5,500 was not made timely. The project is required to make timely monthly deposits to the reserve in the amount of $5,500 per month. b. Action(s) Taken or Planned on the Finding The last amount of $5,500 for the reserve funding for 2023 was missed and then accounted for in February 2024 to fully fund for the 2023 year.

View Audit 322940

Finding 500105 (2023-002)

Material Weakness 2023

Shiloh Manor, Inc.

CT

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll expenses in the amount of $76 on behalf of an affiliate from the project cash without HUD approval. The amount due to the project as of December 31, 2023 is $76. b. Action(s) Taken or Plan...

a. Comments on the Finding and Recommendation During the year ended December 31, 2023, the project paid payroll expenses in the amount of $76 on behalf of an affiliate from the project cash without HUD approval. The amount due to the project as of December 31, 2023 is $76. b. Action(s) Taken or Planned on the Finding 1 The finding for the $76 are items deducted from Shiloh Manor due an error with the setup of payroll processing with Paychex that resulted in a few items deducted from the bank account that should have been for First Housing Corp. It was eventually fixed with Paychex in 2024 and the amount was accounted for as Accounts Receivable - Other as a due from First Housing Corp. A transfer will be made in 2024 for the total of the balance due of $75.60 from First Housing Corp to Shiloh Manor to correct.

View Audit 322940 Questioned Costs: $1

Finding 500104 (2023-001)

None 2023

Shiloh Manor, Inc.

CT

HUD Housing Programs Matching / Level of Effort / Earmarking

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In 2017, HUD had approved a loan to operations from the reserve for replacement to be repaid upon receipt of the past due subsidy. When the subsidy was received, the property was unable to repay the loan be...

a. Comments on the Finding and Recommendation We concur with the auditors finding as follows: In 2017, HUD had approved a loan to operations from the reserve for replacement to be repaid upon receipt of the past due subsidy. When the subsidy was received, the property was unable to repay the loan because of an unexpected increase in vacancies as a result of tenant turnover. The loan has not yet been repaid. During 2022, property transferred $9,000 of reserve for replacement funds to operations to fund payroll and operating payables; the funds have not been reimbursed as of December 31, 2023. b. Action(s) Taken or Planned on the Finding The 2022 transfer from reserve of $9,000 was not returned as of 2023. A conversation with HUD on May 29, 2024, lead to a decision being made with a payment plan of $1,500 per month to start on June 1, 2024. As of December 31, 2023, there was a meeting with HUD representatives on March 23, 2023, resulted in the decision for the waiver of the balance owed to the reserve of the $40,239. We are awaiting documentation from HUD on this decision.

View Audit 322940

Finding 500103 (2023-001)

Significant Deficiency 2023

Cassia

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

COVID-19 Provider Relief Funding – Assistance Listing No. 93.489 Recommendation: Management of Cassia and Support Corporations should review the lost revenues included on the reporting submissions to ensure the lost revenues agree with the internal financial statements. Explanation of disagreement...

COVID-19 Provider Relief Funding – Assistance Listing No. 93.489 Recommendation: Management of Cassia and Support Corporations should review the lost revenues included on the reporting submissions to ensure the lost revenues agree with the internal financial statements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a review process of the lost revenues that are being reported in the Provider Relief Fund reporting portal to ensure the lost reviews being reported tie to the internal financial statements. Name(s) of the contact person(s) responsible for corrective action: Kathy Youngquist, CFO Planned completion date for corrective action plan: September 2024

View Audit 322937

Finding 500102 (2023-002)

Significant Deficiency 2023

City of Wausau

WI

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.214

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that ar...

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will take actual computer image snips of the search results. Name(s) of the contact person(s) responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2024

View Audit 322932

Finding 500100 (2023-003)

Material Weakness 2023

City of Wausau

WI

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal...

Federal Funding Accountability and Transparency Act- CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various grant requirements and laws surrounding the CDBG grant program and ensure that any written internal control or procedure manuals include all of the required compliance requirements. We also recommend that the City ensure multiple individuals are trained on the administration of the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz Planned completion date for corrective action plan: 10/14/2024

View Audit 322932

Finding 500098 (2023-001)

Significant Deficiency 2023

City of Wausau

WI

Allowable Costs / Cost Principles Reporting Significant Deficiency

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the repo...

Reporting and Environmental Reviews – CDBG Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Recommendation: We recommend the City review the various requirements of the CDBG grant program and identify individuals who can act as a reviewer and approver of the reporting process. We also recommend the City document these procedures and internal controls as required by Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community Development Manager and/or Community Development Specialist will prepare all Draw Requests and complete CDBG reports, including, but not limited to, the Annual Action Plan, CAPER, 5-Year Consolidated Plan, Labor Standards Report, and Minority/Women-Owned Business Reports. All Draw Requests will be reviewed by the Finance Director or Assistant Director, while other reports will be reviewed by the Development Director prior to submission to ensure accuracy and compliance. This process will be added to the CDBG Policy and Procedure Manual to address the audit findings and improve reporting oversight. Name(s) of the contact person(s) responsible for corrective action: Tammy Stratz, Randy Fifrick Planned completion date for corrective action plan: 9/30/2024

View Audit 322932

Finding 500059 (2023-003)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 322924 Questioned Costs: $1

Finding 500026 (2023-004)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Subrecipient Monitoring

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment an...

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment and monitoring that are in place from the Research department. We will leverage key resources within the organization to address areas of noncompliance. Responsible Official: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE

View Audit 322924 Questioned Costs: $1

Finding 500004 (2023-005)

Significant Deficiency 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved...

Finding 2023-005 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple As soon as the annual rate is calculated and reviewed after the annual audit is complete, Research will provide the approved fringe rate to accounting. Accounting will use the approved rate prospectively. Accounting will assess the variance between the new approved rate and the prior rate used. Research will approve the adjustment based on materiality and document the adjustment process. Management will develop a policy around the fringe allocation and adjustment Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office and Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 322924

Finding 500000 (2023-002)

Material Weakness 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles Reporting

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 322924

Finding 499999 (2023-001)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconcil...

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 322924

Finding 499998 (2023-003)

Material Weakness 2023

Wayne Township

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The...

FINDING 2023-003 (Medicaid Cluster – Activities Allowed or Unallowed, Allowable Costs/Cost Principles) Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number: 317-418-7855 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a wellestablished CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then inputted into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/24

View Audit 322923

Finding 499980 (2023-002)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Reporting Significant Deficiency

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or i...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. According to NSLDS Enrollment Reporting Guide, “At a minimum, schools are required to certify enrollment every 60 days, and respond within 15 days of the date that NSLDS sends a Roster file to the school or it’s third-party servicer.” And “Rosters will be sent to schools no less frequently than every two months.” It seems RGM did not receive the rosters from NSLDS thus the Enrollment Reporting was not filed in a timely manner. The school will work closely with the third-party servicer and monitor the NSLDS Enrollment Reporting from now on, effective September 23, 2024.

View Audit 322916

Finding 499979 (2023-001)

Significant Deficiency 2023

Acupuncture and Integrative Medicine College, Berkeley

CA

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the N...

The NSLDS Enrollment Reporting has been reporting to NSLDS by the third-party servicer RGM. A reminder will be posted in RGM and the school will review the monthly roster. The school will work closely with the third-party servicer to make sure correct student status information is reported to the NSLDS from now on. Effective completion September 24, 2024

View Audit 322916

Finding 499978 (2022-003)

None 2023

Bossier Office of Community Services, Inc.

LA

Reporting

2022-006 Federal Financial Reporting RECOMMENDATION: Management should develop and implement procedures to ensure that complete and accurate Federal Financial Reports are prepared, reviewed, and submitted in a timely manner. CORRECTIVE ACTION PLAN: Note resolved. See finding 2023-006.

View Audit 322911

Finding 499977 (2022-002)

None 2023

Bossier Office of Community Services, Inc.

LA

2022-005 Program Governance RECOMMENDATION: Management should consider alternatives for preparing and reviewing monthly financial reports in the event financial management staff are unavailable in the future to perform these duties in a timely manner. CORRECTIVE ACTION PLAN: Partially resolved. ...

2022-005 Program Governance RECOMMENDATION: Management should consider alternatives for preparing and reviewing monthly financial reports in the event financial management staff are unavailable in the future to perform these duties in a timely manner. CORRECTIVE ACTION PLAN: Partially resolved. See finding 2023-005.

View Audit 322911

Finding 499976 (2022-001)

Material Weakness 2023

Bossier Office of Community Services, Inc.

LA

2022-004 Financial Management RECOMMENDATION: All detailed general ledger account balances should be reviewed and reconciled on a monthly basis to ensure complete and accurate financial information is provided to all users of the financial information. CORRECTIVE ACTION PLAN: Unresolved. See fin...

2022-004 Financial Management RECOMMENDATION: All detailed general ledger account balances should be reviewed and reconciled on a monthly basis to ensure complete and accurate financial information is provided to all users of the financial information. CORRECTIVE ACTION PLAN: Unresolved. See finding 2023-004.

View Audit 322911

Finding 499969 (2023-003)

None 2023

Bossier Office of Community Services, Inc.

LA

Reporting

The Finance Director was responsible for completion and submission of the Federal Financial Reports (SF-425). To ensure complete and accurate Federal Financial Reports are prepared, reviewed, and submitted in a timely manner, the Agency has contracted a CPA firm to review financial records and make...

The Finance Director was responsible for completion and submission of the Federal Financial Reports (SF-425). To ensure complete and accurate Federal Financial Reports are prepared, reviewed, and submitted in a timely manner, the Agency has contracted a CPA firm to review financial records and make any corrections for submission of the Federal Financial Report (SF-425)

View Audit 322911

Finding 499968 (2023-002)

None 2023

Bossier Office of Community Services, Inc.

LA

The Finance Director was responsible for processing and preparation of monthly financial statements. To ensure that the Board receive monthly financial reports at each Board meeting, the Agency has contracted a CPA firm to perform services for review for accuracy monthly financial statements for the...

The Finance Director was responsible for processing and preparation of monthly financial statements. To ensure that the Board receive monthly financial reports at each Board meeting, the Agency has contracted a CPA firm to perform services for review for accuracy monthly financial statements for the Board. In the absence of Finance Director, the Bookkeepers along with Executive Director is responsible for processing the reports to be provided to the Board.

View Audit 322911

Finding 499967 (2023-001)

Material Weakness 2023

Bossier Office of Community Services, Inc.

LA

Matching / Level of Effort / Earmarking § 200.302

The Finance Director was responsible for ensuring that bank accounts are reconciled accurately and on a monthly basis. Due to performance, the finance director has been terminated and the agency has contracted with a CPA firm to review and make any corrections to account reconciliations.

View Audit 322911

Finding 499966 (2023-002)

Significant Deficiency 2023

Town of Erie

CO

Procurement, Suspension & Debarment Subrecipient Monitoring

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No.21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal. Explanation of Disagreement with Audit Finding: There is no disagreemen...

COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No.21.027 Recommendation: The Town should update all contracts to include a suspension and debarment paragraph to verify status with every renewal. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The Town agrees that suspension and debarment documentation was not properly kept. The Town has met with their legal counsel to update all contract templates to include a clause or conidiation regarding suspension and debarment. This review will be completed by the finance department prior to entering into the contact with each entity. The documentation should include the certification from the vendor or reference the contract that includes the clause or condition regarding suspension and debarment. Name of the Contact Person Responsible for Corrective Action: Sara Hancock, Finance Director Planned Completion Date for Corrective Action Plan: The checklist for compliance has already been put in place for confirming a vendor is compliant. The Town’s legal counsel will provide templates no later than December 2024. If the Department of the Treasury has questions regarding this plan, please call Sara Hancock, Finance Director at 303-926-2750.

View Audit 322905

Finding 499961 (2023-010)

Significant Deficiency 2023

Kandiyohi County

MN

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.403

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreem...

SOCIAL SERVICES ACTIVITIES ALLOWED/ALLOWABLE COSTS Recommendation: It is recommended that the County continue to be diligent in their review of what is allowable when coding to certain account codes that flow into the DHS reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to better capture disallowed costs getting reported. Name of the contact person responsible for corrective action plan: Karen Anderson, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2024

View Audit 322900 Questioned Costs: $1

Corrective Action Plans

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