Corrective Action Plans

Finding 1172319 (2024-004)

Material Weakness 2024

AK

Subrecipient Monitoring Material Weakness Reporting

Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and tim...

Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2026

View Audit 385350

Finding 1172316 (2024-001)

Material Weakness 2024

Alexia Manor Housing Corporation

OH

Internal Control / Segregation of Duties

(a) Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. (b) Action(s) Taken or Planned: 2024-001: The underfunded replacement reserve deposit will be deposite...

(a) Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. (b) Action(s) Taken or Planned: 2024-001: The underfunded replacement reserve deposit will be deposited into the replacement reserve account as cash flow allows during fiscal year 2025. Furthermore, internal controls over replacement reserve funding are being strengthened to prevent future non-compliance.

View Audit 385347

Finding 1172298 (2024-007)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Reporting § 200.510

Finding 2024-007 – Schedule of Expenditures of Federal Awards (SEFA) – Incorrect CFDA / Assistance Listing Numbers Reporting; Internal Control over Compliance (Significant Deficiency) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Gr...

Finding 2024-007 – Schedule of Expenditures of Federal Awards (SEFA) – Incorrect CFDA / Assistance Listing Numbers Reporting; Internal Control over Compliance (Significant Deficiency) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife FoundationAssistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Under 2 CFR 200.510(b), auditees must prepare a complete and accurate SEFA including correct Assistance Listing (formerly CFDA) numbers, program names, and amounts. This is essential for proper identification of federal programs and determination of major programs. Condition: The SEFA for fiscal year ended June 30, 2024 was provided after asking for the SEFA repeatedly. When finally received, the SEFA contained incorrect Assistance Listing numbers for multiple programs/awards, which could lead to misclassification of federal awards. Context: The SEFA reported $1,381,646 in federal expenditures across 27 programs/grant agreements. Testing revealed that 23 of the 27 grant awards had incorrect Assistance Listing numbers on the SEFA and were not aligned with agreements or program information. The SEFA was finalized, only after significant auditor follow-up. Cause: Management did not have adequate procedures for compiling and reviewing SEFA information, including verification of Assistance Listing numbers against official sources and award documents. Effect or Potential Effect: Incorrect CFDA / Assistance Listing numbers may:  Impair auditor’s ability to properly identify major programs,  Result in noncompliance with Uniform Guidance reporting requirements,  Increase risk of audit findings and questioned costs in future periods. Questioned Cost: None identified Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Establish a formal SEFA preparation process, including a checklist for verifying Assistance Listing numbers against award documents and official listings, Assign responsibility for timely SEFA submission, and require supervisory review before providing to auditors.  Maintain documentation supporting CFDA/ Assistance Listing numbers and program details in a centralized grant file. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: ____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: ___________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172271 (2024-006)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Subrecipient Monitoring Procurement, Suspension & Debarment Material Weakness § 200.301 § 200.328 § 200.329 § 200.334

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environ...

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of AgricultureFederal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Under 2 CFR 200, recipients must submit performance and financial reports as required by the terms and conditions of the award and must retain records sufficient to demonstrate compliance (see (§200.301Monitoring and reporting program performance, and §200.328 Financial reporting, §200.329 Monitoring and reporting program performance, and §200.334 Retention requirements for records). The grant agreements for awards above require timely submission of performance / progress reports by specified due dates, with documentation maintained to support the submitted information. Condition: For the fiscal year ended June 30, 2024, the auditee could not provide sufficient evidence that required reports for the programs listed were prepared, reviewed, and submitted in accordance with grant terms. Specifically:  No provided required financial reports, and Partnership for the Umpqua Rivers lacked copies or evidence of submission, and support for reported amounts requested.  Auditors were not provided with performance/progress reports and were instructed that Partnership for the Umpqua Rivers had no retained copies, review sign-offs, or submission confirmation.  Where payments were received, support for the required reports or metrics were not retained and could not be supplied to auditors for reconciling to underlying records. Cause: Management has not implemented formal reporting controls, including:  A documented reporting calendar with due dates and responsible staff,  Reconciliation of report amounts to the accounting records,  Retention procedures for report copies, underlying support, and submission confirmations, and  Supervisory review evidenced by signatures or workflow approvals. Effect or Potential Effect: Absent evidence of timely, accurate reporting and adequate record retention:  The organization is at risk of noncompliance with federal award conditions,  Inaccurate financial or performance information may be reported to the funding agency, and  The entity may be subject to remedial actions, including heightened monitoring, repayment of questioned amounts, or potential suspension of funding. Questioned Cost: None directly noted, but potential risk if reports were incomplete or inaccurate.Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. Award files provided to auditors did not contain information related to reporting of activity, expenditures, or progress of the awards. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Establish a formal reporting and retention policy aligned with 2 CFR 200 and grant terms.  Implement a centralized reporting calendar that tracks due dates, preparers, reviewers, and submission methods.  Require reconciliations of financial reports to the general ledger and supporting schedules, retain the reconciliation with the reporting package.  Create standard workpapers for performance metrics for each award.  Configure the grant portal or document management system to retain submission confirmations, reports, receipts, and version -controlled copies of all reports for awards.  Document supervisory review through sign-offs prior to submission and with evidence retained.  Provide training to staff on Uniform Guidance requirements and record retention (§200.334). District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: ____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _____________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172244 (2024-005)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Procurement, Suspension & Debarment § 200.213 § 200.214 § 200.317 § 200.318 § 200.319

Finding 2024-005 – Inadequate Procurement Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name...

Finding 2024-005 – Inadequate Procurement Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the InteriorFederal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Federal procurement standards require non-Federal entities to maintain records sufficient to detail the history of procurement, including the method of procurement, selection of contract type, contractor selection or rejection, and basis for the contract price. Competitive procurement must follow the entity’s written procedures consistent with 2 CFR §§200.317-200.327, including:  Written procedures for procurement (§200.318(a)).  Full and open competition requirements (§200.319).  Methods of procurement (sealed bids, proposal requirements, and required documentation (§200.320).  Contract cost and price justification, (§200.324).  Suspension/debarment verification for covered transactions (§200.214; §200.213). Condition: During the audit period, the Entity did not retain sufficient procurement documentation for several contracts funded under the above Assistance Listings. Specifically, files lacked one or more of the following:  Evidence of the procurement method used.  Price or cost analysis.  Suspension/debarment checks for vendors where required.  Documentation of competition.  Conflict-of-interest attestations. Cause: Partnership for the Umpqua Rivers procurement procedures were not sufficiently detailed or consistently applied to federal purchases. No evidence of procedures or review for procurement or suspension / debarment was provided to auditors. Turnover and limited training on Uniform Guidance procurement standards contributed to the inconsistent file completeness. Effect or Potential Effect: Without complete procurement documentation, the Entity cannot demonstrate compliance with federal procurement requirements, increasing the risk of:  Noncompetitive awards or unreasonable prices.  Unallowable costs for the award requirements.  Potential disallowance or repayment of federal funds.  Findings in federal or pass-through monitoring and future audits. Questioned Cost: Yes, $902,496 related to expenditures that had no procurement support or detail. Context: During our audit, it was found that the Partnership for the Umpqua Rivers had experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. Award files provided to auditors did not contain information related to procurement, suspension or debarment procedures or processes. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers: Update Written Procurement Procedures o Incorporate Uniform Guidance thresholds and methods (§200.320), competition requirements (§200.319), and documentation expectations (history of procurement). o Embed steps for suspension / debarment checks and Appendix II Contract clauses.  Standardized Procurement Checklist o Pre-award checklist that verifies: method, competition evidence, cost/price analysis, conflict of interest attestations, SAM exclusion check, and required federal clauses. o Post -award checklist ensuring complete contract file (award memo, bid tab / evaluation, signed agreement, clause verification).  Cost/Price Analysis Guidance o Require documented price reasonableness for small purchases, formal cost or price analysis for larger or sole-source awards, per (§200.324).  Training & Accountability o Provide targeted training to procurement and program staff on 2 CFR §§200.317- 20.327 and Assistance Listing award conditions. o Implement supervisory pre-award review and periodic file audits. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: ____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _____________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172217 (2024-004)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.302 § 200.303

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Env...

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land ManagementCriteria: Under Uniform Guidance 2 CFR §200.303, non-federal entities must establish and maintain effective internal control over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the award terms and conditions. This includes ensuring that:  Personnel administering federal awards possess adequate skills, knowledge, and experience.  Management and leadership provide appropriate oversight of federal award activities.  Financial management systems adequately support accurate reporting, documentation, retention, and reconciliation of federal expenditures in accordance with 2 CFR §200.302. Condition: During the audit of federal awards, the entity did not demonstrate sufficient skills, knowledge, or experience of the staff and leadership responsible for administering and overseeing federal programs. Specifically:  Adequate supporting documentation for federal award expenditures was not maintained or provided.  Leadership oversight of federal award compliance activities was limited, and management review of grant activity were not evidenced. These conditions resulted in weaknesses in financial reporting, compliance monitoring, and documentation related to federal awards. Cause: Partnership for the Umpqua Rivers has not ensured that staffing levels, qualifications, and experience are sufficient to support federal award administration and compliance. In addition, leadership lacks adequate knowledge of federal award requirements to provide effective governance, oversight, and monitoring of compliance activities. Formal training and documented procedures for federal awards management have not been prioritized. Effect or Potential Effect: As a result of these deficiencies:  Partnership for the Umpqua Rivers is at increased risk of non-compliance with Uniform Guidance requirements.  Federal expenditures may be unsupported, inaccurately reported, or unallowable.  Errors or compliance violations may not be detected or corrected in a timely manner.  The entity may be subject to questioned costs, repayment of federal funds, or additional scrutiny from grantor agencies. Questioned Cost: None identified Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Ensure staff responsible for federal awards receive appropriate training on Uniform Guidance requirements, grant financial management, documentation, and compliance monitoring. Assign federal award oversight to personnel with sufficient experience and qualification or obtain external grant management and accounting support as needed.  Establish written policies and procedures for federal award administration, including expenditure documentation, reconciliation, compliance review, and management approvals.  Require leadership to perform and document periodic oversight and monitoring of federal awards, including review of reconciliations reimbursement requests, and compliance metrics.  Implement ongoing monitoring and internal control assessments to ensure compliance with federal award requirements. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: ___________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172190 (2024-003)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Reporting Subrecipient Monitoring § 200.302 § 200.303 § 200.430

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Enviro...

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation ServiceName of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Title 2 CFR §200.303 requires nonfederal entities to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing the awards in compliance with federal statutes, regulations, and the terms and conditions of the award. Additionally, 2 CFR §200.302(b)(3) requires entities to maintain records that adequately identify the source and application of funds, including supporting documentation for expenditures, and 2 CFR §200.430 requires documentation for compensation for personal services. Condition: During our review of expenditures charged to the federal programs, the entity was unable to provide invoice copies or other sufficient supporting documentation for certain expenditures tested. As a result, we could not verify the allowability, accuracy, and proper approval of these costs in accordance with federal requirements. In addition, records were unavailable for Personnel expenditures that were charged to grant awards, and no support or evidence of time per grant was available. Cause: Partnership for the Umpqua Rivers does not have effective internal controls in place to ensure that invoice documentation and other supporting records are retained, centrally filed, and readily available for audit and monitoring purposes. In addition, management did not perform ongoing monitoring to verify that required documentation was maintained prior to reimbursement or reporting. Effect or Potential Effect: because supporting documentation was not available, expenditures from detail documentation could not be substantiated. This increases the risk that the unallowable, unsupported, or inaccurate costs may be charged to the federal program and reported in the Schedule of Expenditures of Federal Awards (SEFA). Questioned Cost: Yes, $332,409 related to Personnel costs, equipment and other purchases that were not documented with detailed support. Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit.Recommendation: Partnership for the Umpqua Rivers should implement policies and procedures requiring invoice copies and supporting documentation to be maintained for all grant expenditures. Management should strengthen record retention practices, provide training to staff on documentation requirements, and implement periodic internal reviews to ensure compliance. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172106 (2024-001)

Material Weakness 2024

Coordinated Behavioral Care

NY

Reporting Significant Deficiency § 200.512

Management remains committed to full compliance with federal reporting requirements. Once all outstanding filings are brought up to date, we will ensure that future submissions are completed within the required deadlines.

View Audit 385259

Finding 1172089 (2024-002)

Material Weakness 2024

Housing Authority of the City of Conway

AR

HUD Housing Programs Allowable Costs / Cost Principles

Action Taken: Management acknowledges the findings and the significant deficiency in internal control. We accept responsibility for the deficiencies in internal control over payroll reporting and are committed to implementing corrective actions as follows to ensure a robust control environment that ...

Action Taken: Management acknowledges the findings and the significant deficiency in internal control. We accept responsibility for the deficiencies in internal control over payroll reporting and are committed to implementing corrective actions as follows to ensure a robust control environment that ensures payroll transactions are verified against authorized documentation. • Comprehensive File Reviews: We have immediately begun reviewing all current employee payroll files to confirm that they are complete. • Verify Documentation: We have immediately begun ensuring each employee file contains proper documentation for initial pay rates, compensation changes, and job descriptions and offer letters, where applicable. The Authority has implemented a checks and balances review process to ensure that time is entered accurately, reviewed and signed on by the employee and the employee's supervisor, and then Authority leadership also conducts a pre-payroll audit. • Internal Controls: The Authority currently uses a third-party, Paycom, to manage its payroll functions and for recordkeeping purposes. Timesheets are entered and approved electronically in the system. Pre-payroll audits are conducted by the CEO and COO, prior to payroll being approved for payment. With the current electronic record keeping system, payroll documents are securely stored, easily searchable, and traceable. • Ongoing Compliance: The HR Directorwill conduct semi-annual internal audits of a sample of employee files to confirm and document ongoing compliance. In addition, staff who input and review payroll will receive ongoing compliance training and file documentation. Name of Responsible Person: Catherine Lamberg, CEO and Jackie Otto COO, and Natalie Hawks. HR Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by March 1, 2026.

View Audit 385225

Finding 1172088 (2024-003)

Material Weakness 2024

Housing Authority of the City of Conway

AR

Procurement, Suspension & Debarment HUD Housing Programs § 200.318

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in procurement. We accept responsibility for the deficiencies in internal control over procurement and are committed to implementing corrective actions that address missing doc...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in procurement. We accept responsibility for the deficiencies in internal control over procurement and are committed to implementing corrective actions that address missing documentation and lack of verifiable procurement procedures to ensure compliance. • Implement Standardized Procurement Procedures: Update and implement a forma', written procurement policy that clearly outlines the procedures for sealed bids, proposals, and small purchases. • Mandatory Documentation Checklist: Create a procurement file checklist for every contract to ensure all required documents—such as the independent cost estimate, advertisement, bidder list, evaluations, and justification for award—are included in the procurement file. • Supervisory Review Process: A supervisor will review and sign off on the procurement file checklist before a contract is executed. • Staff Training: Provide comprehensive training to all staff involved in procurement to ensure they understand H U D's procurement standards, including requirements forf ull and open competition and proper record-keeping. • Maintain Records: Ensure that all documentation for the full procurement cycle is maintained, including evidence that contractors are not debarred or suspended. Name of Responsible Person: Catherine Lamberg, CEO and Jackie Otto, COO, and Natalie Hawks, Procurement Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by May 1, 2026.

View Audit 385225

Finding 1172086 (2024-006)

Material Weakness 2024

Housing Authority of the City of Conway

AR

Subrecipient Monitoring HUD Housing Programs Reporting

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address mis...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address missing self-certification documentalion to ensure compliance. The Authority must take immediate steps to remediate these deficiencies by establishing a robust, auditable documentation process: • Strengthen Internal Controls: Develop procedures to ensure complete and accurate documentation is maintained for all 14 SEMAP indicators, including detailed sampling methodologies. • Pre-Certification Review: Implement a mandatory management review process for all SEMAP documentation before final certification is submitted to HUD. • Ensure Proper Retention: Enforce document retention policies that align with HUD regulations, ensuring records are accessible for audit purposes. • Staff Training: Provide training to staff regarding SEMAP indicator requirements and the necessity of maintaining supporting evidence. • Utilize PIG Reports: Ensure all tenant data is properly reported in PlC, as this is the basis for several indicators. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Most of the corrective activities are completed. We anticipate completing the balance of activities by May 1, 2026.

View Audit 385225

Finding 1172085 (2024-005)

Material Weakness 2024

Housing Authority of the City of Conway

AR

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in its waiting list management. We accept responsibility for the deficiencies in internal control over the waiting list and are committed to implementing corrective actions tha...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in its waiting list management. We accept responsibility for the deficiencies in internal control over the waiting list and are committed to implementing corrective actions that address missing documentation and lack of transparency in following the Authority's Administrative Plan and HUD guidelines when selecting applicants from its waiting list. Immediate corrective actions include: • Only using the electronic records of applicants from the Authority's housing software and not creating external waiting lists. • Reconcile and Reconstruct: Immediately reconcile the waiting list and reconstruct missing documentation for voucher issuance. • Cleanup Waiting List: The Authority's waiting list is closed, and staff are currently working to purge it. • Update Procedures: Ensure staff know and are trained on waiting list procedures to ensure compliance with HUD regulations and the Authority's Administrative Plan. • Implement Controls: Establish a periodic supervisory review to verify document completeness during the voucher issuance process. • Training: Provide staff with ongoing training on proper, consistent, and compliant wailing list administration. • Retention: Ensure all records are maintained according to federal retention requirements. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by June 1, 2026.

View Audit 385225

Finding 1172084 (2024-004)

Material Weakness 2024

Housing Authority of the City of Conway

AR

HUD Housing Programs

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in allowability and eligibility. We accept responsibility for the deficiencies in internal control over allowability and eligibility and are committed to implementing correctiv...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in allowability and eligibility. We accept responsibility for the deficiencies in internal control over allowability and eligibility and are committed to implementing corrective actions that address missing documentation and lack of verifiable procurement procedures to ensure compliance. • Immediate File Correction & Review: Correct all identified deficiencies in the sampled files. Furthermore, a 100% review of the remaining -335 files must be conducted to identify if these errors are systematic [1.1]. • Repayment and Re-calculation: For files with incorrect income, utility allowance, or payment standards, the Authority must recalculate the Housing Assistance Payments (HAP) and determine if repayments to HUD are necessary. • Strengthen Internal Controls: • Implement a File Checklist: Require a mandatory, signed checklist for all new admissions and annual recertifications to ensure all 214 forms, 9886 forms, income verifications, and ID documentation are present. • Supervisory Review: Implement a mandatory, independent supervisory review of a percentage of files before HAP payments are authorized. • Inspection Tracking System: Utilize automated tools to track HQS inspection dates to prevent late or missed inspections. • Training: Provide staff training on HUD eligibility, income verification, and rent calculation procedures, specifically focusing on the requirements in 24 CFR Part 5. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Some of the corrective activities are underway. We anticipate completing these activities by June 1, 2026.

View Audit 385225

Finding 1172067 (2024-004)

Material Weakness 2024

Carter County Fiscal Court

KY

Allowable Costs / Cost Principles Special Tests & Provisions § 200.303

I have been working with CDBG grants for 25 years and have never had a problem with having invoices or anything else. [Grant administrator name redacted] was administering the grant and failed to give me all the needed documents. In the future I will make sure to get the documents.

View Audit 385202

Finding 1172059 (2024-001)

Material Weakness 2024

Greater Baltimore Medical Center, INC

MD

Reporting

Management will strengthen internal controls over the reporting of expenditures on the schedule of expenditures of federal awards (SEFA) to ensure it is complete and accurate. The Company will provide additional training to staff to better understand the importance of the reporting requirements and ...

Management will strengthen internal controls over the reporting of expenditures on the schedule of expenditures of federal awards (SEFA) to ensure it is complete and accurate. The Company will provide additional training to staff to better understand the importance of the reporting requirements and how to properly record federal awards in the general ledger. Management will work directly with the accounting and grants departments when the Company receives new awards to ensure that all award information is reviewed appropriately to determine if it is a federal award.

View Audit 385185

Finding 1172051 (2024-001)

Material Weakness 2024

City of Hughes, AR Federal Awards

AR

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Cor...

Recommendation:We recommend that management develop, implement, and maintain written policies and procedures documenting its system of internal control over federal programs to ensure compliance with Uniform Guidance and applicable federal requirements. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and plans to develop and implement written internal control policies and procedures over federal programs. Management anticipates completion by June 30, 2026.

View Audit 385167

Finding 1172037 (2024-004)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Procurement, Suspension & Debarment § 200.318

2024-004 Procurement, Suspension and Debarment The Committee acknowledges that certain procurement procedures were not followed, leading to a finding of noncompliance. To remedy this, on July 1, 2025 we put new workflow controls in place within our new integrated accounting software. These workflows...

2024-004 Procurement, Suspension and Debarment The Committee acknowledges that certain procurement procedures were not followed, leading to a finding of noncompliance. To remedy this, on July 1, 2025 we put new workflow controls in place within our new integrated accounting software. These workflows support compliance with our procurement policies and ensure all required supporting documentation, including forms for micro and small purchases, are secured and archived for capital purchases and grant expenditures. This will ensure that all procurement policies, which are in compliance with all FTA guidelines, are consistently followed.

View Audit 385115

Finding 1172036 (2024-003)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Allowable Costs / Cost Principles § 200.302

2024-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft ...

2024-003 Allowable Costs/Cost Principles: Written Financial Policies The Biddeford-Saco-Old Orchard Beach Transit Committee acknowledges the need to formally adopt certain written financial management policies as outlined in federal regulations. The new finance manager is currently working to draft and formalize these policies and procedures with a targeted completion date of March 31, 2026. We will present them to the Board of Directors for review and official adoption.

View Audit 385115

Finding 1172035 (2024-002)

Material Weakness 2024

Biddeford-Saco-Old Orchard Beach Transit Committee

ME

Allowable Costs / Cost Principles § 200.303

2024-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all empl...

2024-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all employees are now required to create a purchase order (PO) and obtain approvals before payments can be made. This process controlled by the finance manager creates a complete audit trail for every transaction, ensuring that all disbursements are properly documented.

View Audit 385115

Finding 1171960 (2024-005)

Material Weakness 2024

Galveston County Health District

TX

Eligibility Material Weakness Internal Control / Segregation of Duties

Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective act...

Finding: 2024-005 Material Weakness in Internal Control Over Eligibility – WIC Special Supplemental Nutrition Program for Women, Infants, and Children (10.557) Corrective Action: We will develop a checklist for eligibility documentation and conduct quarterly file reviews and implement corrective actions as a result of those reviews. We will also provide training to program staff on the eligibility documentation requirements. Proposed Completion Date: February 28, 2026 Name of Contact Person:Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171959 (2024-003)

Material Weakness 2024

Galveston County Health District

TX

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper...

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper indirect cost rate is applied to the various grants. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171958 (2024-002)

Material Weakness 2024

Galveston County Health District

TX

Reporting Material Weakness Period of Performance

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process ...

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process of developing a comprehensive year-end closing checklist and has already streamlined many of the procedures that caused reconciliation issues. In addition, we will perform spot checks on transactions to ensure that payroll and nonpayroll expenditures are recorded in the proper period. We will also provide additional training to ensure that personnel only record expenditures when confirmation has been received of receipt of goods or services. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171947 (2024-004)

Material Weakness 2024

Galveston County Health District

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions

Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits ...

Finding: 2024-004 Material Weakness in Internal Control Over Special Tests – Health Center Program (93.224) Corrective Action: We will develop a checklist for patient discount documentation and implement a control requiring supervisor approval for overrides. We will also perform monthly file audits and report exceptions to the appropriate personnel. Proposed Completion Date: February 28, 2026 Name of Contact Person: Lane Baker, CHW Chief Operating Officer

View Audit 385024

Finding 1171942 (2024-002)

Material Weakness 2024

City of Williamsport

PA

Reporting

Finding 2024-002 Reporting Corrective Action: The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected with 2025 reporting.

View Audit 385019

Finding 1171932 (2024-005)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

Allowable Costs / Cost Principles

Planned Corrective Action: SAVA Center experienced a change in leadership in September 2024. The new Executive Director discovered that several invoices had been submitted to VOCA for reimbursement for costs not approved in the grant budget. The new Executive Director worked with VOCA to submit corr...

Planned Corrective Action: SAVA Center experienced a change in leadership in September 2024. The new Executive Director discovered that several invoices had been submitted to VOCA for reimbursement for costs not approved in the grant budget. The new Executive Director worked with VOCA to submit corrected invoices and withhold the unallowable costs from a subsequent reimbursement request, and created a new grant management tracking system. This system includes an Excel workbook that tracks grant allocations, and grant spending for each individual budget, to ensure SAVA is in compliance. Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: October 31, 2024

View Audit 384965

Corrective Action Plans

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