Corrective Action Plans

Finding 392618 (2023-002)

Material Weakness 2023

OH

Questioned Costs Allowable Costs / Cost Principles § 200.439

The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures,...

The River Valley Board of Education acknowledges that the Federal government requires school districts to get approval for any purchases with a unit cost of $5,000 or more from the federal awarding agency or pass-through entity. The Board and Administration have implemented processes and procedures, which require approval from both the awarding agency or pass-through entity and the Board of Education prior to purchasing any unit at or above the $5,000 threshold.

View Audit 302921 Questioned Costs: $1

Finding 392601 (2023-002)

Significant Deficiency 2023

Chugachmiut

AK

Procurement, Suspension & Debarment § 200.318

Finding 2023-002: Significant Deficiency in Internal Control over Compliance and Noncompliance – Procurement, Suspension, and Debarment Standards. Name of Contact Person: Angela J. Vanderpool, Executive Director. Corrective Action: The finance department will create and implement a checklist that re...

Finding 2023-002: Significant Deficiency in Internal Control over Compliance and Noncompliance – Procurement, Suspension, and Debarment Standards. Name of Contact Person: Angela J. Vanderpool, Executive Director. Corrective Action: The finance department will create and implement a checklist that reflects the finance procurement policy to ensure the policy is followed before a procurement is awarded to a vendor. Proposed Completion Date: June 2024

View Audit 302897

Finding 392600 (2023-003)

Material Weakness 2023

Chugachmiut

AK

Eligibility Internal Control / Segregation of Duties Material Weakness

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to partic...

Finding 2023-003: Material Weakness in Internal Control over Compliance – Eligibility. Name of Contact Person: Phyllis Wimberley, Deputy Director. Corrective Action: The Heritage program will create and implement a checklist of required documentation to ensure all participants are eligible to participate in the program. Proposed Completion Date: June 2024

View Audit 302897

Finding 392591 (2023-001)

None 2023

Westhaven, INC

OH

HUD Housing Programs Procurement, Suspension & Debarment Reporting

Finding Number: 2023-001 Condition: The Corporation failed to refund the security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The Corporation refunded the security deposit 38 days after move out on December 19th, 2023. Contact person responsible for corr...

Finding Number: 2023-001 Condition: The Corporation failed to refund the security deposit to a tenant within 30 days of their move out date. Planned Corrective Action: The Corporation refunded the security deposit 38 days after move out on December 19th, 2023. Contact person responsible for corrective action: Jill Kolb, Vice President – Housing Accounting Anticipated Completion Date: December 31, 2023

View Audit 302882

Finding 392590 (2023-001)

None 2023

National Church Residences Mercedarian of Cleveland, Oh

OH

HUD Housing Programs Reporting

Comments on Findings and Recommendation: Management acknowledges failure to comply with the provisions of the HUD Regulatory Agreement requiring the property to be maintained in good repair and condition. Actions Taken or Planned: The Corporation promptly corrected all exigent health and safety i...

Comments on Findings and Recommendation: Management acknowledges failure to comply with the provisions of the HUD Regulatory Agreement requiring the property to be maintained in good repair and condition. Actions Taken or Planned: The Corporation promptly corrected all exigent health and safety items. Repairs were completed throughout the building in order to ensure compliance with the requirements of the Regulatory Agreement. Status of Corrective Actions on Prior Findings: N/A - No prior year findings.

View Audit 302869

Finding 392589 (2023-001)

Significant Deficiency 2023

Hattiesburg Area Senior Services, Inc. - Wesley Manor I

MS

HUD Housing Programs Reporting Internal Control / Segregation of Duties

March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Hattiesburg Area Senior Services, Inc. (the "Company") ...

March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Hattiesburg Area Senior Services, Inc. (the "Company") for the year ended December 31, 2023. The Correction Plan was necessitated by findings reported by the independent public accounting firm of: HORNE LLP 661 Sunnybrook Road Suite 100 Ridgeland, MS 39157 Current Findings on the Schedule of Findings and Questioned Costs Audit Finding #2023-001 / ALN 14.157 – Equal Housing Opportunity Logo Auditors Recommendation: HORNE recommends that all current marketing materials without the equal housing opportunity logo be corrected and any future materials produced include the equal housing opportunity logo. Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Status of Corrective Actions on the Schedule of Prior Year Audit Findings Audit Finding #2022-001 / ALN 14.157 – Equal Housing Opportunity Logo Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Should you need anything further or have any questions regarding management's plan of correction response, you may contact me at Mississippi Methodist Senior Services, Inc. (662-844-8977) or by email at jim.zuelzke@mss.org. Sincerely, Jim Zuelzke, CFO Mississippi Methodist Senior Services, Inc.

View Audit 302867

Finding 392588 (2023-001)

Significant Deficiency 2023

Lauderdale Se Svcs, Inc. - Aldersgate Retirement Center - Phase I

MS

HUD Housing Programs Reporting Internal Control / Segregation of Duties

March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Lauderdale Senior Services, Inc. (the "Company") for th...

March 26, 2024 Healthcare Account Executive U.S. Department of Housing and Urban Development 451 7th Street, S.W. Washington, DC 20410 Mississippi Methodist Senior Services, Inc. respectfully submits the following corrective action plan for Lauderdale Senior Services, Inc. (the "Company") for the year ended December 31, 2023. The Correction Plan was necessitated by findings reported by the independent public accounting firm of: HORNE LLP 661 Sunnybrook Road Suite 100 Ridgeland, MS 39157 Current Findings on the Schedule of Findings and Questioned Costs Audit Finding #2023-001 / ALN 14.155 – Equal Housing Opportunity Logo Auditors Recommendation: HORNE recommends that all current marketing materials without the equal housing opportunity logo be corrected, and any future materials produced include the equal housing opportunity logo. Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Status of Corrective Actions on Findings on the Schedule of Prior Year Audit Schedule of Findings and Questions Costs Audit Finding #2022-001 / ALN 14.155 – Equal Housing Opportunity Logo Action Taken: To be cost effective, the current video advertisements are run for a period of time and then updated when the commercial run has ended. Controls have been put in place to ensure the logo is placed on all future marketing materials, especially commercial advertisements. Should you need anything further or have any questions regarding management's plan of correction response you may contact me at Mississippi Methodist Senor Services, Inc. (662-844-8977) or by email at jim.zuelzke@mss.org. Sincerely, Jim Zuelzke, CFO Mississippi Methodist Senior Services, Inc.

View Audit 302866

Finding 392587 (2023-001)

None 2023

Montgomery Supported Housiing INC

TX

Questioned Costs HUD Housing Programs Reporting

Management fees and bookkeeping fees for the year ended December 31, 2023 were overpaid. By $120. Management repaid the $120 on 04/04/2024 by deducting $120 from the management fee for April. Name and Title of contact person responsible for corrective action: Steve Colella, Making a Difference in ...

Management fees and bookkeeping fees for the year ended December 31, 2023 were overpaid. By $120. Management repaid the $120 on 04/04/2024 by deducting $120 from the management fee for April. Name and Title of contact person responsible for corrective action: Steve Colella, Making a Difference in Property Management, LLC; Management Agent; 6800 Park Ten Blvd, Ste 184-W; San Antonio, TX 78213

View Audit 302860 Questioned Costs: $1

Finding 392580 (2023-003)

Significant Deficiency 2023

Bristol Bay Area Health Corporation and Subsidiary

AK

Eligibility Significant Deficiency

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages an...

Finding 2023-003 Eligibility – Noncompliance and Significant Deficiency in Internal Control over Compliance. Planned Corrective Actions: The Organization provided documentation of beneficiary status for 38 of the 40 patients being tested. The remaining two patients were treated in remote villages and there was no documentation in their records. Management has reinforced the policy requiring documentation of beneficiary status and the Patient Access Manager has developed a registration performance improvement plan. Anticipated Completion Date: June 30, 2024.

View Audit 302857

Finding 392523 (2023-004)

None 2023

South County Mental Health Center, Inc.

FL

Reporting § 200.512

Action Taken: A perfect storm of the CFO vacancy (however the organization believed the CFO was coming back soon). It was believed the Controller could handle a short period of absence from the CFO. The extended delay of hiring a competent CFO proved too taxing on the Controller which contributed to...

Action Taken: A perfect storm of the CFO vacancy (however the organization believed the CFO was coming back soon). It was believed the Controller could handle a short period of absence from the CFO. The extended delay of hiring a competent CFO proved too taxing on the Controller which contributed to the Controller’s resignation. A third‐party software conversion in March 2023, a payroll conversion which began in August 2023, and recent turnover of staff in the A/P and A/R positions had placed an enormous load on the controller’s position which is the reason for the late audit and other reports. None of the above is currently an issue and the necessary functions of the accounting and finance areas are performing in a timely manner with the understanding that areas requiring additional analyzes and training will be addressed as we progress into the future. Future reports and audits will be performed in a timely manner.

View Audit 302847

Finding 392511 (2023-011)

Material Weakness 2023

Park County

MT

Procurement, Suspension & Debarment § 200.214 § 200.318 § 200.327

NONCOMPLIANCE WITH PROCUREMENT, SUSPENSION & DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, YEAR ENDED JUNE 30 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reasonabl...

NONCOMPLIANCE WITH PROCUREMENT, SUSPENSION & DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, YEAR ENDED JUNE 30 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward, and that no subaward, contract, or agreement for purchase of goods or services is made with any suspended or debarred party. Proposed Completion Date: Immediately

View Audit 302840

Finding 392509 (2023-013)

Material Weakness 2023

Park County

MT

Allowable Costs / Cost Principles Cash Management

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 112761 AND 112626, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop a process to ver...

NONCOMPLIANCE WITH ALLOWABLE COSTS/COST PRINCIPLES; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No’s 112761 AND 112626, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop a process to verify that amounts reported to the granting agency agree to the general ledger accounting records. Proposed Completion Date: This meeting will take place in January 2024 to develop those procedures.

View Audit 302840

Finding 392508 (2023-012)

Material Weakness 2023

Park County

MT

Questioned Costs Procurement, Suspension & Debarment

NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No 111604, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reaso...

NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; FORMULA GRANTS FOR RURAL AREAS AND TRIBAL TRANSIT PROGRAM; AL No. 20.509, GRANT No 111604, YEAR ENDED JUNE 30, 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward, and that no subaward, contract, or agreement for purchase of goods or services is made with any suspended or debarred party. Proposed Completion Date: Immediately

View Audit 302840 Questioned Costs: $1

Finding 392489 (2023-015)

Material Weakness 2023

City of Laurel

MT

Subrecipient Monitoring Reporting

NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply...

NONCOMPLIANCE WITH REPORTING REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: December 1, 2024

View Audit 302828

Finding 392488 (2023-014)

Material Weakness 2023

City of Laurel

MT

Procurement, Suspension & Debarment § 200.214 § 200.318 § 200.327

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in pla...

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: December 1, 2024

View Audit 302828

Finding 392487 (2023-007)

Material Weakness 2023

Roosevelt County

MT

Procurement, Suspension & Debarment Eligibility § 200.214

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFR...

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

View Audit 302827

Finding 392485 (2023-005)

Significant Deficiency 2023

East Orange Board of Education

NJ

The fixed asset appraisal report be updated annually and include all federally funded capital additions.

View Audit 302822

Finding 392477 (2023-002)

Significant Deficiency 2023

Saline County, Nebraska

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or...

Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or debarred and such procedure will be adequately documented. Anticipated Completion Date: Ongoing Responsible Party: Phil Hardenburger, Saline County Board of Commissioners, Chairperson

View Audit 302796

Finding 392476 (2023-001)

None 2023

St Camillus Residential Health Care Facility

NY

HUD Housing Programs

CORRECTIVE ACTION PLAN St. Camillus Residential Health Care Facility respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 N. Franklin Street, Suite 100 Syracuse, New York 1320...

CORRECTIVE ACTION PLAN St. Camillus Residential Health Care Facility respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Bonadio & Co., LLP 432 N. Franklin Street, Suite 100 Syracuse, New York 13204 Audit Period: January 1, 2023 – December 31, 2023 The finding from the 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding 2023-001 - Section 232 HUD Insured Mortgage, 14.129 Condition: St. Camillus Residential Health Care Facility (the Facility) has an outstanding receivable from its affiliate, Integrity Home Care Services, Inc. (Integrity), amounting to $435,362. Recommendation: The Facility management should contact HUD representative if the previously communicated repayment plan changed significantly. Action Taken: Integrity Home Care Services, Inc is in the process of being sold to Comfort Care 247. All proceeds from the sale will go towards the repayment of the receivable balance. The sale is currently under review by the New York State Department of Health. If you have any questions regarding this plan, please contact Michael Zingaro at 315-703-0646 or via email at Michael.Zingaro@St-Camillus.org Sincerely, Michael Zingaro Vice President of Finance St. Camillus RHCF

View Audit 302792

Finding 392475 (2023-002)

Material Weakness 2023

Barium Springs Home for Children

NC

Matching / Level of Effort / Earmarking

Finding: 2023-002 Name of contact person: Celeste Dominguez, President and CEO Corrective Action: Management of Barium Springs Home for Children will formalize and implement written policies that comply with Uniform Guidance standards. Proposed Completion Date: April 30, 2...

Finding: 2023-002 Name of contact person: Celeste Dominguez, President and CEO Corrective Action: Management of Barium Springs Home for Children will formalize and implement written policies that comply with Uniform Guidance standards. Proposed Completion Date: April 30, 2024

View Audit 302783

Finding 392474 (2023-001)

Significant Deficiency 2023

Barium Springs Home for Children

NC

Internal Control / Segregation of Duties

Finding: 2023-001 Name of contact person: Celeste Dominguez, President and CEO Corrective Action: Management of Barium Springs Home for Children will establish formal internal controls procedures related to the approval of payroll prior to its submission. Management will mon...

Finding: 2023-001 Name of contact person: Celeste Dominguez, President and CEO Corrective Action: Management of Barium Springs Home for Children will establish formal internal controls procedures related to the approval of payroll prior to its submission. Management will monitor those procedures to ensure they are performed. Proposed Completion Date: Immediately.

View Audit 302783

Finding 392472 (2023-001)

Significant Deficiency 2023

Sonoran University of Health Sciences

AZ

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding....

Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that the University review the updated GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sonoran University will implement the corrective action suggestions outlined in the audit findings, including: • Expansion of vulnerability mitigation to include the prescribed penetration and exploitation operations. • Complete migration of Sonoran servers vendor-supported versions (as of this writing, only two systems remaining). • Implementation of a phishing campaign education initiative for Sonoran University Employees. • Update WISP documents to meet the prescribed documentation requirements. • Build University-consistent data retention strategy. Name of the contact person responsible for corrective action: • Paul Collins, Senior Director of IT, Sonoran University. Planned completion date for corrective action plan: • Completion of all items by September 30, 2024.

View Audit 302771

Finding 392470 (2023-001)

Significant Deficiency 2023

Pennsylvania Virtual Charter School

PA

Procurement, Suspension & Debarment

Pennsylvania Virtual Charter School management agrees with the above recommendation and has instituted policies and procedures designed to address this finding: 1) Clarified that the appropriate persons are receiving audit notifications, and 2) Subsequent due dates are included in the organizationa...

Pennsylvania Virtual Charter School management agrees with the above recommendation and has instituted policies and procedures designed to address this finding: 1) Clarified that the appropriate persons are receiving audit notifications, and 2) Subsequent due dates are included in the organizational and departmental and administrative calendars.

View Audit 302767

Finding 392396 (2023-003)

Material Weakness 2023

Sicangu Oyate Ho, INC

SD

Special Tests & Provisions Material Weakness

Management Response: Local background checks were completed, however when a consultant was hired to complete the federal background checks, the files were stalled at the adjudicator’s office in Albuquerque, NM due to some billing issues with the Tribe. We have 3 trained staff who are certified adjud...

Management Response: Local background checks were completed, however when a consultant was hired to complete the federal background checks, the files were stalled at the adjudicator’s office in Albuquerque, NM due to some billing issues with the Tribe. We have 3 trained staff who are certified adjudicators however it was recommended to use an outside adjudicator and we were able to locate someone locally who agreed to perform the federal background checks. Anticipated Completion Date: Currently in progress March 31, 2024 Responsible Party: Troy Lunderman, HR Director Leah Running Bear, HR Assistant Independent adjudicator Jodee Wike

View Audit 302745

Finding 392395 (2023-002)

Significant Deficiency 2023

Sicangu Oyate Ho, INC

SD

Reporting Significant Deficiency

Management Response: The School will ensure that the Single Audit reporting package is completed and submitted within the timeline as required by Uniform Guidance. Anticipated Completion Date: March 31, 2025 Responsible Party: Maria Walking Eagle, Business Manager

View Audit 302745

Corrective Action Plans

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