Corrective Action Plans

Finding 400874 (2022-005)

Significant Deficiency 2022

GA

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated ...

Name of the Contact Person Responsible: Rodney Green, Deputy Chief Financial Officer Corrective Action Plan: The City will strengthen its internal controls over federal reporting to ensure compliance with all requirements of the federal award program and other reporting requirements. Anticipated Completion Date: June 30, 2024

View Audit 308897

Finding 400808 (2022-010)

Material Weakness 2022

Healthhiv

DC

Allowable Costs / Cost Principles Material Weakness

We have immediately taken corrective action to properly enhance our internal control for verifying program expenses.

View Audit 308831

Finding 400807 (2022-009)

Material Weakness 2022

Healthhiv

DC

Procurement, Suspension & Debarment

This action is a continued from the prior year due to the transitioning of key staff members that left the organization. We immediately implemented corrective actions to make ensure we have permanent copies of our supporting documents to solidify our vendor selections in adherence to federal regula...

This action is a continued from the prior year due to the transitioning of key staff members that left the organization. We immediately implemented corrective actions to make ensure we have permanent copies of our supporting documents to solidify our vendor selections in adherence to federal regulations.

View Audit 308831

Finding 400806 (2022-008)

Material Weakness 2022

Healthhiv

DC

Material Weakness Reporting Internal Control / Segregation of Duties

The transitioning to the new Finance Director continued during year and additional account reviews were required. This has caused a delay in the timing of our filing. HealthHIV will continue to addressed our internal control on filing our audit report timely and by the FAC due date.

View Audit 308831

Finding 400774 (2022-005)

Significant Deficiency 2022

Great Northwest Education Cooperative

ND

Reporting

Contact Person – Ben Schafer, Executive Director Corrective Action Plan – Form SF-425 will be reported based on accrual basis general ledger balances. Completion Date – The Coop will implement this corrective action plan for the June 30, 2024 filing.

View Audit 308791

Finding 400773 (2022-004)

Significant Deficiency 2022

Great Northwest Education Cooperative

ND

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Contact Person – Ben Schafer, Executive Director Corrective Action Plan – The Executive Director will review and approve, with documentation, all invoices prior to payment being made. Completion Date – The Coop will implement this corrective action plan in the next fiscal year.

View Audit 308791

Finding 400604 (2022-005)

Significant Deficiency 2022

Tca Health, Inc.

IL

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort r...

TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort reporting policy and model. TCA currently feels that what the process that they utilized to allocate salary and wage expense to the grant related to this finding was allowable from a Uniform Grants Guidance perspective, however they were not compliant with their policy and will work to revise their policy to less restrictive (although still in compliance with the UGG). The iCFO will create greater monitoring of the month-end process as it relates to the allocation of payroll costs to be consistent with the personnel activity reports and the Health Center’s revised policy.

View Audit 308641

Finding 400602 (2022-004)

Material Weakness 2022

Tca Health, Inc.

IL

Cash Management Material Weakness Matching / Level of Effort / Earmarking § 200.303

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s c...

The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.

View Audit 308641

Finding 400600 (2022-003)

Material Weakness 2022

Tca Health, Inc.

IL

Eligibility Material Weakness Internal Control / Segregation of Duties

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recordin...

The COO at TCA Health will address the Special Provisions weakness by coaching and training front desk staff members. Specifically, staff will be trained in the sliding fee scale and its requirements. Staff will become proficient in the collection of data from patients, properly storing and recording it in the EMR, and the calculation of the slide according to the Federal Poverty Guidelines. Lastly, the team will be updated on the latest EMR module that experienced an upgrade and taught how to effectively apply the slide. TCA will also assess the current staff to ensure the proper personnel is in in place.

View Audit 308641

Finding 400572 (2022-003)

Material Weakness 2022

Lutheran Family Services of Nebraska, Inc. and Affiliates

NE

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. T...

Condition: Refugee case files, specifically related to the Afghan Placement and Assistance Program, lacked certain documentation required by the Cooperative Agreements. Planned Corrective Action Management is reviewing and improving internal controls over review of refugee case file documentation. The Cooperative Agreement specific to the Afghan Placement and Assistance Program directed the Organization to focus on the provision of services and to include documentation of such activities to the extent possible. Furthermore, the Organization’s funding agencies have performed numerous monitoring reviews of the case files, including reviews specific to the Afghan Placement and Assistance Program. While the results of these reviews did note similar findings, subsequent to year-end, the Organization received written documentation that all such findings have satisfactorily been resolved and that the Organization is in compliance with the terms and conditions of the Cooperative Agreement. Contact Person: Amy Carolus, Chief Financial Officer Anticipated Completion Date: December 31, 2023

View Audit 308632

Finding 400569 (2022-002)

Material Weakness 2022

Lutheran Family Services of Nebraska, Inc. and Affiliates

NE

Reporting

Condition: The Organization does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the Schedule. Planned Corrective Action: Management is revie...

Condition: The Organization does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the Schedule. Planned Corrective Action: Management is reviewing and improving internal controls over preparation of the schedule of expenditures of federal awards required by the Uniform Guidance to ensure completeness and accuracy of reporting of federal awards expended. Contact Person: Amy Carolus, Chief Financial Officer Anticipated Completion Date: December 31, 2023

View Audit 308632

Finding 400566 (2022-006)

Material Weakness 2022

Pembroke Hill School

NH

Questioned Costs School Nutrition Programs Internal Control / Segregation of Duties § 200.303

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve effi...

Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs

View Audit 308621 Questioned Costs: $1

Finding 400560 (2022-002)

Significant Deficiency 2022

Kentucky Refugee Ministries, Inc.

KY

Significant Deficiency

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Clearinghouse. Action Taken: KRM has taken steps to increase the staffing in the finance department to help with the increased number of refugees served as well as implementing new software changes to ...

Recommendation: KRM should have future audits completed timely and filed timely with the Federal Clearinghouse. Action Taken: KRM has taken steps to increase the staffing in the finance department to help with the increased number of refugees served as well as implementing new software changes to streamline processes for more efficient operations.

View Audit 308596

Finding 400552 (2022-003)

Significant Deficiency 2022

Meals on Wheels of Middle Georgia, Inc.

GA

Internal Control / Segregation of Duties Special Tests & Provisions

Views of Responsible Officials and Planned Corrective Actions: See Comment 2022-001 and 002. Date to be implemented: See Comment 2022-001 and 002. Persons responsible: See Comment 2022-001 and 002.

View Audit 308581

Finding 400454 (2022-005)

Significant Deficiency 2022

Douglas County Board of Commissioners

GA

Questioned Costs Procurement, Suspension & Debarment § 200.318

Corrective Action Plan: We have taken proactive measures within the Purchasing Department to enhance training and awareness among our staff. Additionally, the Grant division has been reinforcing the importance of adhering to Federal grant guidelines regarding procurement. We will continue to monitor...

Corrective Action Plan: We have taken proactive measures within the Purchasing Department to enhance training and awareness among our staff. Additionally, the Grant division has been reinforcing the importance of adhering to Federal grant guidelines regarding procurement. We will continue to monitor and improve our processes to ensure compliance with established guidelines. Anticipated Completion Date: December 2024

View Audit 308475 Questioned Costs: $1

Finding 400453 (2022-007)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged ...

Finding No. 2022-007 - Community Development Block Grants/Entitlement Grants Federal Assistance Listing Number #14.218 Statement of Condition: Owner paid one vendor invoice, of eight tested, that was not listed on the CDBG Address List as reported to Portland Housing Bureau (“PHB”) and charged through to and was reimbursed by PHB under their CDBG Grant. Corrective Action: Since the time of this we have made some changes to have the appropriate funding code on each client’s folder/information so that it is easy to see where to charge when making a purchase and the CBP manager is reaching out to PHB on resolution to this instance.

View Audit 308469 Questioned Costs: $1

Finding 400452 (2022-006)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Special Tests & Provisions HUD Housing Programs § 200.857

Finding No. 2022-006 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner did not provide proof to REAC that all health and safety inspection findings were solved within 72 hours. Corrective Action: ...

Finding No. 2022-006 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner did not provide proof to REAC that all health and safety inspection findings were solved within 72 hours. Corrective Action: REACH responded and resolved all Exigent Health & Safety within the 72 hour period, but did not submit the confirmation report until 5 business days after the review, REACH will retain evidence of same day repairs going forward to allow confirmation that the time frame was met.

View Audit 308469

Finding 400451 (2022-005)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding No. 2022-005 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner was unable to provide the Management Entity Profile HUD 9832 documentation for one of two properties tested and approved Mana...

Finding No. 2022-005 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: The owner was unable to provide the Management Entity Profile HUD 9832 documentation for one of two properties tested and approved Management Agent's Certification HUD 9839-B for one of two properties tested. Corrective Action: REACH has contacted HUD office to request missing copies of HUD approved Management entity profile and certifications.

View Audit 308469 Questioned Costs: $1

Finding 400450 (2022-004)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs

Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files i...

Finding No. 2022-004 - Low Income Housing Preservation and Resident Homeownership Act of 1990) Federal Assistance Listing Number #99.999 Statement of Condition: Our testing procedures noted that the owner did not perform certifications and recertifications timely, did not maintain tenant files in compliance with HUD Rules in Code of Federal Regulations at 24 CFR Part 92, and did not select tenants from the waitlist appropriately. Corrective Action: Management has policies and procedures in place, compliance has been impacted by being understaffed while recovering from covid-related social distancing/limited on site presence. This resulted in recertification and move-in compliance issues. Compliance team and the new HUD Portfolio Manager have been providing trainings for the HUD managers in 2023 and will continue to do so in 2024. In 2022 and 2023, Compliance Manager ensured that all staff who needed access to EIV took the appropriate steps (Cyber Awareness Training, updated EIV authorizations) to access EIV for their properties to run the reports timely. In 2023, The HUD Portfolio Manager created an EIV workflow training for the HUD managers. Both the Compliance team and HUD managers were present. One Compliance Specialist with HUD experience has been filling in and assisting at the HUD properties where we continue to be understaffed. As a Below Market Interest Rate (“BMIR”), we do not receive HUD subsidy or oversight from HUD. Because both properties are due for Affirmative Fair Housing Marketing Plan (“AFHMP”) updates, we will submit an updated plan to HUD for review and approval in 2024. Management is aware and has been performing Move-out inspections with tenants whenever possible.

View Audit 308469

Finding 400449 (2022-003)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs

Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is ...

Finding No. 2022-003 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not make available to HOME tenants the contracted number and type of HOME units. Corrective Action: A unit will be re-classified the next time there is a vacant unit of the corresponding size/type.

View Audit 308469

Finding 400448 (2022-002)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Eligibility HUD Housing Programs

Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance ...

Finding No. 2022-002 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: In connection with our lease file review we noted one instance of eight tenants tested where management did not perform a 3rd party income verification in accordance with policy. Corrective Action: Community Manager reviewed file noting 2017 and 2018 were both done as self-certifications. REACH is currently doing full reviews for all HOME units during 2023.

View Audit 308469

Finding 400447 (2022-001)

Significant Deficiency 2022

Reach Community Development, Inc.

OR

Special Tests & Provisions HUD Housing Programs Matching / Level of Effort / Earmarking

Finding No. 2022-001 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not ensure passing HQS inspections were performed during 2022. Corrective Action: Unit inspections are being done for 2023.

View Audit 308469

Finding 400392 (2022-004)

None 2022

Appalachian Headwaters INC

WV

Reporting § 200.512

Appalachian Headwaters aims to submit future Single Audits to the Federal Audit Clearinghouse prior to the required deadline to ensure all compliance requirements are met.

View Audit 308440

Finding 400391 (2022-003)

Significant Deficiency 2022

Appalachian Headwaters INC

WV

Procurement, Suspension & Debarment Cash Management Reporting

Corrective action has already been taken. Appalachian Headwaters requests and receives detailed invoices for all employee reimbursements which include amounts, descriptions of items purchased, and delivery locations, when possible. Appalachian Headwaters pays vendors directly whenever possible.

View Audit 308440

Finding 400380 (2022-004)

Material Weakness 2022

Bradley Cleveland Community Services Agency

TN

Period of Performance

Management agrees with the finding and has determined it was due to a grant specific issue that they should not have moving forward. They will continue to monitor grant expenditures to be sure they are only submitted within the period performance.

View Audit 308423

Corrective Action Plans

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