Corrective Action Plans

Finding 2206 (2022-002)

Material Weakness 2022

IA

Internal Control / Segregation of Duties Reporting

The District will continue to review and evaluate staff assignments and areas where additional internal control is necessary. The District Office Manager and Administrative Assistant continue to learn new roles and divide responsibilities in the area of payroll processing, data entry, receiving and...

The District will continue to review and evaluate staff assignments and areas where additional internal control is necessary. The District Office Manager and Administrative Assistant continue to learn new roles and divide responsibilities in the area of payroll processing, data entry, receiving and general ledger at the District level. We are utilizing online payments for lunch accounts, registration and for some activities to reduce overall exposure with cash candling. We have also changed some roles for associates, secretaries and a kitchen assistant to ensure daily deposits, receipts and receipt entry are not under the control of one person.

View Audit 3787

Finding 2166 (2022-002)

Material Weakness 2022

Housing Authority of the City of Omaha

NJ

Questioned Costs HUD Housing Programs Eligibility

Finding Reference Number: 2022-001 Recommendation The Authority should ensure proper internal controls, which include timely monthly reconciliations of account balances, are in place to prevent material weaknesses from occurring. Reporting views of responsible officials Auditee agrees with the au...

Finding Reference Number: 2022-001 Recommendation The Authority should ensure proper internal controls, which include timely monthly reconciliations of account balances, are in place to prevent material weaknesses from occurring. Reporting views of responsible officials Auditee agrees with the auditor and management will be responsible for implementing the corrective action plan. Completion date or proposed completion date: December 31, 2023 Action(s) taken or planned on the finding Gary Hatfield is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring. Finding Reference Number: 2022-002 Recommendation We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Reporting views of responsible officials The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Chief Financial Officer who will implement the required safeguards and ensure that the Authority follows its Section 8 Administrative Plan and the HUD compliance requirements to remedy the aforementioned deficiencies. Completion date or proposed completion date: December 31, 2023 Action(s) taken or planned on the finding Gary Hatfield is responsible for ensuring proper internal controls are in place to prevent significant deficiencies and material weaknesses from occurring.

View Audit 3737 Questioned Costs: $1

Finding 2162 (2022-002)

Significant Deficiency 2022

Biostl

MO

Procurement, Suspension & Debarment

Finding No. 2022-002 Significant Deficiency Personnel Responsible For Corrective Action: Mike Higgins, Vice President of Development, Christina Green, Vice President of Finance and Human Resources, Procurement and Compliance Officer, to be hired, Grant Manager, to be hired Anticipated Completion Dat...

Finding No. 2022-002 Significant Deficiency Personnel Responsible For Corrective Action: Mike Higgins, Vice President of Development, Christina Green, Vice President of Finance and Human Resources, Procurement and Compliance Officer, to be hired, Grant Manager, to be hired Anticipated Completion Date: Completed Corrective Action Plan: Along with strengthening of reporting, the hiring of the dedicated Grants Coordinator position additionally improved controls related to procurement. Updated internal forms to document purchasing and classify procurement requirements were established and integrated with project management tools; new procurement templates were established; and improved repositories for cataloguing procurement materials and invoices were established. Additionally, in 2023, as noted above, BioSTL created a new position to ensure internal programmatic and financial control for grants – initiating the hiring of a new Grants Manager role that has already been posted to our website and recruiting has begun. This role will have more dedicated time and responsibility for internal controls and be responsible for oversight and effectiveness of all internal controls – above and beyond existing and previous supervisory review from the VP, Development and SVP, Programs. In 2024, a Procurement and Compliance Officer role is being added to further ensure internal controls for all contracts are adhered to and to provide further structure around the processes. The required language provided by the EDA is included in all BioSTL contracts as specifically noted by the EDA. There is not a call out specifically to suspension and disbarment, however, the language provided by the EDA entails these aspects. Moving forward, the suspension and disbarment language will now be included specifically in all contracts and has been added into the contract template.

View Audit 3729

Finding 2161 (2022-001)

Significant Deficiency 2022

Biostl

MO

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2022-001 Significant Deficiency Personnel Responsible For Corrective Action: Mike Higgins, VP of Development; Ben Johnson, SVP of Programs; and Grant Manager, to be hired Anticipated Completion Date: Completed Corrective Action Plan: Of the six reports selected for testing, the specific ...

Finding No. 2022-001 Significant Deficiency Personnel Responsible For Corrective Action: Mike Higgins, VP of Development; Ben Johnson, SVP of Programs; and Grant Manager, to be hired Anticipated Completion Date: Completed Corrective Action Plan: Of the six reports selected for testing, the specific grant report found to be 7 days after the deadline fell at a time of employee transition – when a prior employee with responsibility for report filing moved on to another role at another company and a newly created Grants Coordinator position was filled to take over responsibility. Given the timing of the on-boarding process and education around EDA processing, the report was submitted 7 days late. It should be noted that all subsequent reports were submitted timely. With the establishment of the dedicated Grants Coordinator position (the timing of which coincided with the timing of the cited report), improved controls came into place – namely: 1) dual supervisory review of reports between the direct supervisor of theGrants Coordinator position and the legacy supervisory role of the Senior Vice President Programs; 2) a clearer timeline of reporting was established with project management systems and document repositories (e.g., Salesforce, Asana, and Box) with additional reminders in place to ensure adequate notice is provided to individuals responsible for providing information; and 3) there is a structured follow-up process, at periodic intervals, for report review to ensure deadlines are met. Additionally, in 2023, BioSTL created another new position to ensure internal programmatic and financial control for grants – initiating the hiring of a new Grants Manager role that has already been posted to our website and recruiting has begun. This role will have more dedicated time and responsibility for internal controls and be responsible for timeliness on all reporting and to monitor against all compliance requirements – above and beyond existing and previous supervisory review from the VP, Development and SVP, Programs.

View Audit 3729

Finding 2157 (2022-002)

Material Weakness 2022

Easton Valley Community School District

IA

Internal Control / Segregation of Duties Reporting

The District will continue to look into our internal controls and review procedures to ensure we are operating efficiently as possible with limited staff numbers.

View Audit 3728

Finding 2123 (2022-001)

Significant Deficiency 2022

Housing Authority of Plainfield

NJ

In response to audit finding 2022-001 cited in the Authority’s audit report as of December 31, 2022, please be advised that it is the Authority’s policy is to follow appropriate procedures with respect to properly maintaining tenant files of the Housing Choice Vouchers program. However, during ye...

In response to audit finding 2022-001 cited in the Authority’s audit report as of December 31, 2022, please be advised that it is the Authority’s policy is to follow appropriate procedures with respect to properly maintaining tenant files of the Housing Choice Vouchers program. However, during year 2022 our Housing Manager resigned and has not been replaced as yet. Her responsibilities were assumed by the Assistant Housing Manager who was not as experienced nor fully trained to assume the responsibilities. Because of the shortage in personnel as a result of the Housing Manager’s resignation, normal monitoring procedures were not performed which led to the deficiencies cited in the audit report.

View Audit 3669

Finding 2123 (2022-001)

Significant Deficiency 2022

Housing Authority of Plainfield

NJ

Subsequently, the Assistant Housing Manager has received and will continue the receive on-going training in procedures of the Housing Choice Vouchers program. We will also continue our monitoring procedures by periodically examining an appropriate selection of tenant files to ensure compliance with...

Subsequently, the Assistant Housing Manager has received and will continue the receive on-going training in procedures of the Housing Choice Vouchers program. We will also continue our monitoring procedures by periodically examining an appropriate selection of tenant files to ensure compliance with the Program’s requirements. Furthermore, we will seek to hire a new, experienced Housing Manager.

View Audit 3669

Finding 2123 (2022-001)

Significant Deficiency 2022

Housing Authority of Plainfield

NJ

As the disruption is service caused by the pandemic comes to an end, we anticipate that we will be able to perform Housing Quality Inspections in accordance with the Housing Choice Vouchers program.

View Audit 3669

Finding 2111 (2022-003)

Material Weakness 2022

Calhoun Liberty Hospital Association INC

FL

Questioned Costs Reporting Internal Control / Segregation of Duties

FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and ...

FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Planned Corrective Action: The Association will ensure the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from patient care. One of the supplemental payments is related to the hospital's eligibility to receive the associated payment under the Medicaid Rural Disproportionate Share Hospital (ROSH) Program or the Rural Financial Assistance Program (RFAP). The RFAP is based upon a fixed sum of money. Therefore, the annual RFAP distribution received by a hospital represents an amount proportional to the hospital's contribution for providing indigent and Medicaid care as compared to all other RFAP eligible rural hospitals and is calculated in accordance with Florida statute. In addition, the Directed Payment Program (OPP}, as approved by the Florida legislature in 2021, provides funding for hospitals that provide inpatient and outpatient services to Medicaid managed care enrollees. This program is intended to address the shortfall to hospitals by collecting Intergovernmental Transfers (IGTs) and Local Provider assessments (LP) to draw down Federal Medicaid Matching dollars.

View Audit 3663 Questioned Costs: $1

Finding 2104 (2022-004)

Material Weakness 2022

Lincoln Hall

NY

Allowable Costs / Cost Principles

For the year ended June 30, 2022 audit, the audit team noted that certain costs were not being recorded in the payroll system timely and correctly on a monthly basis. Process changes have been implemented but we are currently still working to “de-bug” certain parts of our allocation and direct-cha...

For the year ended June 30, 2022 audit, the audit team noted that certain costs were not being recorded in the payroll system timely and correctly on a monthly basis. Process changes have been implemented but we are currently still working to “de-bug” certain parts of our allocation and direct-charge processes; these are captured in the corrective action plan. We believe that these actions will make a significant impact in preventing any needed reallocation of costs at year-end and provide us with accurate cost allocations on a monthly basis.

View Audit 3654

Finding 2103 (2022-003)

Material Weakness 2022

Lincoln Hall

NY

Reporting

During the audit, BDO noted that two SF-PPR quarterly reports, two quarterly SF-425 reports, and the annual required financial reporting were not filed on time; certain of these reports did not follow the period reporting requirements of the grant (e.g., the October to December report requirement wa...

During the audit, BDO noted that two SF-PPR quarterly reports, two quarterly SF-425 reports, and the annual required financial reporting were not filed on time; certain of these reports did not follow the period reporting requirements of the grant (e.g., the October to December report requirement was reported using November to January). Further, the Uniform Guidance report was not submitted on time. We have been taking several steps to reinforce adherence to the reporting process. These actions have included staff trainings and a review our current policies and procedures. We are working on aligning the reports generated by our accounting system to be consistent with the requirements reported on the SF-425. We are producing monthly reports to verify charges to the FRP program (as well as other programs) are correctly charged and allocated. The goal of our corrective actions is to significantly limit instances of noncompliance with this requirement.

View Audit 3654

Finding 2102 (2022-002)

Material Weakness 2022

Lincoln Hall

NY

Allowable Costs / Cost Principles Cash Management Material Weakness

For the year ended June 30, 2022 audit, the audit team noted that payroll, personnel costs, and other than personnel service expenses were not being allocated by cost center on a monthly basis. This issue resulted in errors in the amount charged to various programs resulting in the need for a materi...

For the year ended June 30, 2022 audit, the audit team noted that payroll, personnel costs, and other than personnel service expenses were not being allocated by cost center on a monthly basis. This issue resulted in errors in the amount charged to various programs resulting in the need for a material allocation adjustment. In accordance with Uniform Guidance 200.405, costs that benefit multiple programs should be allocated to the programs based on the proportional benefit. Lincoln Hall did not have the adequate cost allocation mechanisms in place to properly allocate expenses throughout the year. We have been taking several steps to address the issue with allocating costs. The Federal Award Finding and Questioned Costs Finding Number 2022-002 is a result of the initial way in which the general ledger and payroll systems were set up, requiring the majority of allocation work to be done manually in Excel. These manual allocations were done in detail after fiscal year-end to ensure our financial statements at year-end were not misstated. However, this detailed allocation work was not being done on a monthly basis. We have upgraded the Serenic Navigator accounting system two times to improve its accounting capabilities and have also implemented additional allocation processes including allocation of payroll expenses of federal awards. We currently use line-item allocations in The Serenic Navigator for direct costs that are allocated when invoices are paid. During FY 2022 we are continuing to review and revise our process in order to allocate expenses (particularly payroll costs) in the general ledger on a monthly basis for allocations in the past that were performed at the end of the fiscal year. The goal of our corrective actions is to significantly limit the material reallocation of costs by function at year-end and provide us with accurate cost allocations on a monthly basis. This will allow for more accurate reporting on a month-to-month basis and, therefore, will generate more timely and accurate financial information, thereby improving our compliance with cash management during the grant period.

View Audit 3654

Finding 2101 (2022-001)

Material Weakness 2022

Lincoln Hall

NY

Allowable Costs / Cost Principles Material Weakness

For the year ended June 30, 2022 audit, the audit team noted that payroll and personnel costs were not being recorded in the payroll system correctly on a monthly basis. This issue resulted in errors in the amount charged to various programs during the year and resulted in the need for a material al...

For the year ended June 30, 2022 audit, the audit team noted that payroll and personnel costs were not being recorded in the payroll system correctly on a monthly basis. This issue resulted in errors in the amount charged to various programs during the year and resulted in the need for a material allocation adjustment after fiscal year-end. As payroll allocations were a major driver in other than personnel service (OTPS) expense allocations, OTPS costs also required material allocations adjustments at year end. Lincoln Hall has continued our remedial efforts for this audit findings. In 2017, we upgraded the Serenic Navigator accounting software from the 2007 version to the 2013 version, and from the 2013 version to the 2017 version in December 2019. The intent of these upgrades was to strengthen our controls and visibility into accounting records. Furthermore, we have been working on correcting the accounting process related to charging payroll and other applicable costs directly to the appropriate programs. Lincoln Hall began the process of reviewing its financial system and processes and implementing changes in fiscal year (FY) 2020 though these process changes took longer than originally expected due to delays as a result of the COVID-19 pandemic. Process changes have been implemented but we are currently still working to “de bug” certain parts of our allocation and direct charge processes; these are captured in the corrective action plan. For example, internal controls have been improved upon ensuring that employees are appropriately classified to programs within the Paychex system. Reviews are performed each pay period to verify employee’s allocability to programs. We believe that these actions will make a significant impact in preventing the material reallocation of costs by function at year-end and provide us with accurate cost allocations on a monthly basis.

View Audit 3654

Finding 2095 (2022-002)

Significant Deficiency 2022

Sapphire Community Health, Inc.

MT

Reporting § 200.512

Sapphire Community Health has contracted with an accounting and consulting firm to review records and procedures and to make recommendations for future use in June 2023 and have already begun implementing recommendations.

View Audit 3653

Finding 2087 (2022-004)

Significant Deficiency 2022

Jewish Community Services, Inc.

MD

Allowable Costs / Cost Principles Subrecipient Monitoring Significant Deficiency § 200.303

Allowable costs Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is ...

Allowable costs Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding:. JCS will ensure all expenses are properly allocated to the correct funding source. Name of the contact person responsible for corrective action: Nicole Wheeler, Controller Planned completion date for corrective action plan: June 30, 2024

View Audit 3645

Finding 2086 (2022-003)

Significant Deficiency 2022

Jewish Community Services, Inc.

MD

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

Reporting Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is no dis...

Reporting Emergency Rental Assistance Program - Federal Assistance Listing Number: 21.023 Recommendation: We recommend that the Organization implement the proper policies and procedures to ensure compliance with 2 CFR section 200.303. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: JCS will adopt a two-step process for grant reporting to ensure that deadlines are properly met. Grant reporting process begin will once the month ends and reports will be reviewed two days before the submission is due to ensure all reporting requirements are satisfied. Name of the contact person responsible for corrective action: Nicole Wheeler, Controller Planned completion date for corrective action plan: June 30, 2024

View Audit 3645

Finding 2076 (2022-001)

None 2022

Eastern Connecticut Housing Organization

CT

Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in...

Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in accordance with the budget. -2- Cause: Budgeted transfers were not made before yearend to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account.

View Audit 3623

Finding 2075 (2021-001)

None 2022

Eastern Connecticut Housing Organization

CT

2021-001 SECURITY DEPOSITS Criteria: Tenant security deposit accounts must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for tenant security deposits, it was not fully funded. Cause: ...

2021-001 SECURITY DEPOSITS Criteria: Tenant security deposit accounts must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for tenant security deposits, it was not fully funded. Cause: The tenant security deposits subledger is not reconciled with the tenant security deposits bank account to ensure account is fully funded. Effect: Tenant security deposits bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the tenant security deposits bank account is fully funded. Management’s Views and Corrective Action Plan: Management has subsequently corrected this and transferred tenant funds received for their security deposit from the operating bank account to the tenant security deposits bank account to ensure it is fully funded.

View Audit 3623

Finding 2073 (2022-001)

Material Weakness 2022

Bellingham, City of

WA

Subrecipient Monitoring

The City of Bellingham has corrected its oversight in failing to file FFATA reports related to Housing and Services Program federal funding, and all reports are now up to date. In the future, the City will ensure timely reporting with procedures in place for the responsible staff to report regularly...

The City of Bellingham has corrected its oversight in failing to file FFATA reports related to Housing and Services Program federal funding, and all reports are now up to date. In the future, the City will ensure timely reporting with procedures in place for the responsible staff to report regularly and verify reporting is completed via email to the Housing and Services Program Manager.

View Audit 3605

Finding 2072 (2022-005)

Significant Deficiency 2022

Catherine McAuley Center, Inc.

IA

Allowable Costs / Cost Principles Significant Deficiency

Recommendation: Policies and procedures should be in place to ensure indirect costs are properly calculated and adequately approved/reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review p...

Recommendation: Policies and procedures should be in place to ensure indirect costs are properly calculated and adequately approved/reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure indirect costs are properly calculated and adequately approved/reviewed. Name of the contact person responsible for corrective action: Paula Land, Executive Director Planned completion date for corrective action plan: On going

View Audit 3591

Finding 2071 (2022-004)

Material Weakness 2022

Catherine McAuley Center, Inc.

IA

Allowable Costs / Cost Principles Material Weakness Reporting

Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved/reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to...

Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved/reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved/reviewed. Name of the contact person responsible for corrective action: Paula Land, Executive Director Planned completion date for corrective action plan: On going

View Audit 3591

Finding 2023 (2022-002)

Significant Deficiency 2022

Fairfield City Board of Education

AL

Questioned Costs Equipment & Real Property Management § 200.313

The management of the Board was notified of the error and made the adjusting entries to correct the financial statements. The Technology Coordinator and CSFO will review expenditures for non-capitalized equipment more carefully.

View Audit 3535 Questioned Costs: $1

Finding 2022 (2022-004)

None 2022

Tacoma Community House

WA

Questioned Costs Allowable Costs / Cost Principles § 200.402

We have no disagreement with the findings. We will require reconciliation of recorded expenses and actual payments to ensure billing of allowable reimbusable costs is correctly calculated and in agreement with the terms of relevant contracts. We will settle overbilling with the pass through entity. ...

We have no disagreement with the findings. We will require reconciliation of recorded expenses and actual payments to ensure billing of allowable reimbusable costs is correctly calculated and in agreement with the terms of relevant contracts. We will settle overbilling with the pass through entity. the Executive Director, Aimee Khuu will be responsible for ensuring that the corrective actions take place as described. if you have any questions or require additional information, please feel free to contact her at 253-383-3951 Ext 105 or akhuu@tacomacommunityhouse.org.

View Audit 3534 Questioned Costs: $1

Finding 2021 (2022-003)

Material Weakness 2022

Tacoma Community House

WA

Allowable Costs / Cost Principles Material Weakness

This is a reiteration of Finding 2022-002. Please refer to corrective action plan under finding 2022-002 as follows:We have no disagreement with the findings. Tacoma Community House will implement procedures to ensure disbursements are supported and approved before payment. Recurring payments will b...

This is a reiteration of Finding 2022-002. Please refer to corrective action plan under finding 2022-002 as follows:We have no disagreement with the findings. Tacoma Community House will implement procedures to ensure disbursements are supported and approved before payment. Recurring payments will be identified and approved at the start of the year. We will require accounts payable personnel to process payments only on documented and approved transactions. We will require credit card holders to limit use of their credit cards on pre-approved purposes, require adequate documentation of the expenses, and prohibit use of credit cared by their staff. Tacoma Community House will establish vendor rellationships with significant vendors and process such vendor purchases through accounts payable. The Executive Director, Aimee Khuu will be responsible for ensuring that the corrective actions take place as descibed. If you have any questions or require additional information, please feel free to contact her at 253-383-3951 Ext 105 or akhuu@tacomacommounityhouse.org.

View Audit 3534

Finding 2013 (2022-001)

None 2022

Fountain Court Consumer Housing Cooperative, Inc.

IN

Questioned Costs

Management will deposit $1,650 into the replacement reserve and confirm future deposits are made in accordance with HUD.

View Audit 3484 Questioned Costs: $1

Corrective Action Plans

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