Corrective Action Plans

Finding 519386 (2022-003)

Significant Deficiency 2022

NJ

Reporting

Contact Person Responsible for Corrective Action: Bob Rosvold, CFO. Corrective Action Taken or Planned: A more timely monthly financial statement close process has been implemented with the creation of checklists and the upgrading of the financial system, including general ledger. Anticipated Comple...

Contact Person Responsible for Corrective Action: Bob Rosvold, CFO. Corrective Action Taken or Planned: A more timely monthly financial statement close process has been implemented with the creation of checklists and the upgrading of the financial system, including general ledger. Anticipated Completion Date: These improvements were initiated in fiscal year 2023 and are under further development in fiscal years 2024 and 2025.

View Audit 338297

Finding 519364 (2022-005)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were b...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: The amounts reported for net patient revenue were based on gross charges and did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit. This process has been put in place and continues monthly during our month-end close meetings to ensure federal grant funds are being reported correctly. The Vice President of Finance, Eric Caldwell, will be the individual responsible for the corrective action plan.

View Audit 338246

Finding 519363 (2022-004)

Material Weakness 2022

Confluence Health

WA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate l...

Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN# 455563741 Finding Summary: Confluence Health selected option II to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27,2020, for the entire period of availability. The budget used in the calculation of lost revenue was not approved for the entire period of availability. The budget used to cover quarters in 2021 and 2022 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.

View Audit 338246

Finding 519256 (2022-004)

Material Weakness 2022

Wakemed

NC

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.327

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement poli...

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement policy to include the relevant sections from the Code of Federal Regulations and will provide education to the areas involved in procurement and use of federal funds on these requirements. Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

View Audit 337911 Questioned Costs: $1

Finding 519255 (2022-003)

Material Weakness 2022

Wakemed

NC

Reporting Material Weakness § 200.502 § 200.508 § 200.510

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timi...

Finding Number: 2022-003 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: The federal funding was not received until fiscal year 2023 while some expenditures were incurred in fiscal year 2022. The timing of events contributed to the oversight on the 2022 SEFA. WakeMed has reeducated staff on the preparation of the SEFA in order to prevent this error from reoccurring.Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

View Audit 337911

Finding 519254 (2022-002)

Significant Deficiency 2022

Wakemed

NC

Eligibility Cash Management Reporting

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance cover...

Finding Number: 2022-002 Condition: WakeMed charged costs associated with ineligible individuals to the grant. Planned Corrective Action: WakeMed identified all HRSA patients with other documented insurance within the system. Each claim was reviewed to identify patients with active insurance coverage. Patients identified with active insurance coverage were considered ineligible for grant purposes, and the HRSA payments are in the process of being refunded. These costs were removed from the SEFA. In addition, WakeMed has written off all outstanding HRSA claims. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

View Audit 337911

Finding 519253 (2022-001)

Significant Deficiency 2022

Wakemed

NC

Reporting Significant Deficiency

Finding Number: 2022-001 Condition: WakeMed reported duplicate expenditures within the Period 2 portal submission. Planned Corrective Action: WakeMed reviewed the portal submission to determine the impact of the error on the amount of Provider Relief Funds recognized and reported on the SEFA. Wake...

Finding Number: 2022-001 Condition: WakeMed reported duplicate expenditures within the Period 2 portal submission. Planned Corrective Action: WakeMed reviewed the portal submission to determine the impact of the error on the amount of Provider Relief Funds recognized and reported on the SEFA. WakeMed has concluded that there was carried forward lost revenue of $26.4 million that is eligible to be applied to the Period 2 funds of $10.9 million. Therefore, there is no impact on the amounts reported on the SEFA. WakeMed has implemented additional review procedures for grant report submissions to ensure the accuracy of the reports in accordance with granting agency’s reporting requirements. Contact person responsible for corrective action: Terry Flynn, Director, Reimbursement Anticipated Completion Date: 06/14/2023

View Audit 337911

Finding 519126 (2022-012)

Material Weakness 2022

Cleveland County

OK

Subrecipient Monitoring Reporting § 200.303

ALN 21.023 - Lack of Internal Controls and Noncompliance with Reporting Requirement – Emergency Rental Assistance Program (Repeat Finding 2021-010) Beginning in October of 2021, the U.S. Department of the Treasury changed the ERA1 and ERA2 reporting requirements. In fact, each quarter of 2021 had va...

ALN 21.023 - Lack of Internal Controls and Noncompliance with Reporting Requirement – Emergency Rental Assistance Program (Repeat Finding 2021-010) Beginning in October of 2021, the U.S. Department of the Treasury changed the ERA1 and ERA2 reporting requirements. In fact, each quarter of 2021 had various reporting changes. The County changed the manner of reporting which did result in difficulty in reconciling. Previous reports had several changes and had to be re-reconciled and amended. Therefore, it was determined to change to reporting when the subrecipient spent, rather than the county. The County contacted the U.S. Department of the Treasury, who stated any, and all reports should be corrected in the next reporting cycle, rather than retrospectively. The County agrees that some of the prior County Clerk’s records were not in proper order. The County has a new Clerk in place as of July 1, 2024, and is working diligently to improve processes and procedures to prevent this from occurring again in the future. Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for fiscal year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to betterserve its citizens.

View Audit 337659

Finding 519125 (2022-007)

Material Weakness 2022

Cleveland County

OK

Questioned Costs Subrecipient Monitoring § 200.208 § 200.332 § 200.339 § 200.501

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting p...

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for Fiscal Year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to better serve its citizens.

View Audit 337659 Questioned Costs: $1

Finding 519000 (2022-002)

Significant Deficiency 2022

The Health Care Authority of the City of Huntsville

AL

Reporting Internal Control / Segregation of Duties § 200.303 § 200.512

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the ...

The Authority strives always to meet all regulatory deadlines. This particular deadline for the Single Audit was complicated by the unprecedented nature of the COVID-19 pandemic (which, for many organizations such as ours, triggered a Single Audit requirement for the first time, and overwhelmed the audit profession with a surge of new Single Audits to conduct that did not exist previously). In the Authority’s case, the situation was further complicated by the fact that we were changing external audit firms moving into this particular reporting period. By the time the incumbent audit firm had issued its Single Audit report for Fiscal 2021, and the successor audit firm could therefore begin the Fiscal 2022 Single Audit, it was already beyond the reporting deadline of March 31, 2023. The Authority will have the same finding for the Fiscal 2023 Single Audit, for the same reason. We are hoping to be able to work successfully with the successor audit firm in order to file our Single Audit for Fiscal 2024 timely on or before March 31, 2025 and also have timely filings thereafter.

View Audit 337494

Finding 518978 (2022-004)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Reporting § 200.512

FINDING 2022-003: Significant Deficiency Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and recommendation. The new Depu...

FINDING 2022-003: Significant Deficiency Late Audit Reporting Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor's finding and recommendation. The new Deputy Director of Finance will play a key role in ensuring adherence to audit timelines and enhancing overall reporting efficiancy.

View Audit 337426

Finding 518977 (2022-003)

Significant Deficiency 2022

House of Hope Community Development Corporation

RI

Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management...

FINDING 2022-003: Significant Deficiency in Internal Control Over Financial Documentation Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

View Audit 337426

Finding 518975 (2022-001)

Significant Deficiency 2022

Thomas Wilbur Homestead, INC

RI

Internal Control / Segregation of Duties

United States Department of Housing and Urban Development Rhode Island Multifamily Program Center Thomas Wilbur Homestead respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Damiano, Burk & Nuttall, P.C. ...

United States Department of Housing and Urban Development Rhode Island Multifamily Program Center Thomas Wilbur Homestead respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Damiano, Burk & Nuttall, P.C. 6 Blackstone Valley Place Suite 109 Lincoln, RI 02865 Audit period: For the year ended June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Establish and maintain documented monthly rent rolls and a current tenant security deposit liability summary into the month-end close process. Action Taken: Management agrees with the auditor’s finding and recommendation. If the United States Department of Housing and Urban Development has questions regarding this plan, please email Laura Jaworski at laura@thehouseofhopecdc.org.

View Audit 337424

Finding 518972 (2022-002)

Significant Deficiency 2022

George Galen Wheeler House INC

RI

HUD Housing Programs

Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Establish and maintain documented monthly rent rolls and a current tenant security deposit liability summary into the month-end close process. Action Taken: Management agrees with the auditor's fin...

Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Establish and maintain documented monthly rent rolls and a current tenant security deposit liability summary into the month-end close process. Action Taken: Management agrees with the auditor's finding and recommendation. If

View Audit 337419

Finding 518971 (2022-001)

Significant Deficiency 2022

George Galen Wheeler House INC

RI

HUD Housing Programs

Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Implement strict segregation of tenant security deposit funds, conduct regular reconciliations, and establish regular record-keeping practices. Action Taken: Management agrees with the auditor's fi...

Section 811 Capital Advance Program and Project Rental Assistance Contract ALN# 14.181 Recommendation: Implement strict segregation of tenant security deposit funds, conduct regular reconciliations, and establish regular record-keeping practices. Action Taken: Management agrees with the auditor's finding and recommendation.

View Audit 337419

Finding 518896 (2022-001)

Significant Deficiency 2022

Rural Coalition

DC

Reporting

Rural Coalition will be implementing clear, standardized procedures for all program and services. We will also be conducting a comprehensive review of current resource allocation and develop a more effective budget management plan so the grant funds can be managed efficiently removing the reporting ...

Rural Coalition will be implementing clear, standardized procedures for all program and services. We will also be conducting a comprehensive review of current resource allocation and develop a more effective budget management plan so the grant funds can be managed efficiently removing the reporting backlog we face frequently.

View Audit 337355

Finding 518847 (2024-006)

Significant Deficiency 2022

Somali Community Link INC

OH

Subrecipient Monitoring § 200.511

Management concurs with the finding and will develop a formal corrective action plan process for addressing findings and deficiencies from audits or inspections. The process will include documentation of actions taken and periodic progress reviews.

View Audit 337223

Finding 518846 (2024-005)

Significant Deficiency 2022

Somali Community Link INC

OH

Reporting § 200.302

Management acknowledges the issue and will establish and document reconciliation procedures to ensure reports are consistent with the general ledger and trial balance for all future Federal programs. This includes periodic review and approval by management.

View Audit 337223

Finding 518845 (2024-004)

Material Weakness 2022

Somali Community Link INC

OH

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.308 § 200.344

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any uno...

Management agrees with the findings and has already initiated corrective actions. Moving forward, budget-to-actual comparisons will be prepared monthly, and any discrepancies will be addressed promptly. The organization will work closely with the cognizant agency to arrange for the return of any unobligated funds or, if applicable, seek authorization to retain the funds for use in other similar programs. This process will ensure proper financial management and compliance.

View Audit 337223 Questioned Costs: $1

Finding 518844 (2024-003)

Significant Deficiency 2022

Somali Community Link INC

OH

Reporting Program Income Internal Control / Segregation of Duties § 200.328

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provid...

Management acknowledges the need to address and enhance this finding. We are committed to implementing new procedures for recording and tracking program income, including documenting its source, amount, and application. These procedures will be put in place within three months, with oversight provided by senior management to ensure proper compliance and effective implementation.

View Audit 337223

Finding 518843 (2024-002)

Material Weakness 2022

Somali Community Link INC

OH

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. ...

The organization has already taken steps and will continue to take immediate action to establish a formal risk management framework. This will include conducting a comprehensive fraud risk assessment and integrating fraud detection and prevention processes into the organization’s internal controls. A formal risk management policy will be developed and adopted within three months, with regular reviews scheduled thereafter to ensure its continued effectiveness and alignment with industry best practices.

View Audit 337223

Finding 518842 (2024-001)

Significant Deficiency 2022

Somali Community Link INC

OH

Allowable Costs / Cost Principles § 200.302

The organization has established financial policies and procedures. However, we recognize that these policies do not fully address all areas specific to federal grant requirements. As a relatively new organization, we understand the importance of enhancing these frameworks to ensure full compliance ...

The organization has established financial policies and procedures. However, we recognize that these policies do not fully address all areas specific to federal grant requirements. As a relatively new organization, we understand the importance of enhancing these frameworks to ensure full compliance with federal guidelines and properly manage federal funds. We are committed to addressing this gap and will take immediate action to develop and implement comprehensive policies and procedures that fully comply with all applicable federal grant requirements. We anticipate that this process will be completed within three months, with oversight from senior management to ensure its thoroughness and effectiveness. In addition, key financial processes, including disbursements, payroll, and grants management, will be updated and aligned with these new policies to ensure sound fiscal management and maintain ongoing compliance with federal standards

View Audit 337223

Finding 518469 (2022-005)

Significant Deficiency 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Significant Deficiency Internal Control / Segregation of Duties

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 sing...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. The FY2022 single program audit will be submitted to the Federal Audit Clearinghouse (FAC} by MACH's CPA firm as soon as completed and released by the audit firm. The audit firm will begin the FY2023 single program audit shortly after the conclusion of the FY22 audit, with submission to the FAC as soon as completed. MACH will work with the audit firm to assure that all subsequent audits are completed timely.

View Audit 336928

Finding 518468 (2022-004)

Material Weakness 2022

Montgomery Area Coalition for the Homeless, Inc.

AL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.61

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Cu...

Corrective Action by MACH: The Mid-Alabama Coalition for the Homeless agrees with this finding. Since the close of the contract year, MACH's Executive Director, accountant, and CPA firm have established a system for coding, submitting, reconciling, and requesting reimbursement from grant funders. Currently, all grant documentation is assembled as transactions occur, and reimbursement requests are submitted to every grant source each month.

View Audit 336928

Finding 518446 (2022-001)

None 2022

Glens Falls Housing Authority

NY

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through their March 31, 2023 and March 31, 2024 fiscal year ends, and is making every effort to get their filings up to date by their March 31, 2025 year end due date.

View Audit 336840

Corrective Action Plans

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