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Corrective Action Plans

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Finding 1156728 (2024-004)
Material Weakness 2024
Roxboro Housing Authority
NC
HUD Housing Programs
2024-004 ALN 14.850 – Public Housing Operating Fund – Special Test – Depository Agreements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Da...
2024-004 ALN 14.850 – Public Housing Operating Fund – Special Test – Depository Agreements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025
View Audit 369076
Finding 1156727 (2024-003)
Material Weakness 2024
Roxboro Housing Authority
NC
HUD Housing Programs Subrecipient Monitoring Eligibility
2024-003 ALN 14.850 – Public Housing Operating Fund - Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025
2024-003 ALN 14.850 – Public Housing Operating Fund - Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025
View Audit 369076
Finding 1156726 (2024-003)
Material Weakness 2024
Amsterdam Housing Authority
NY
HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2024-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will establish internal tracking and reminder systems to ensure all required reports, including the final P&E and AMCC, are completed and submitted to HUD by the required due dates. Grant reporting responsibilities will be clearly assigned, and submission deadlines will be monitored by the Director of Finance to prevent future delays. These procedures will be implemented immediately. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.
View Audit 369074
Finding 1156725 (2024-004)
Material Weakness 2024
Amsterdam Housing Authority
NY
HUD Housing Programs Reporting
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (4) Finding 2024-004 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will strengthen procedures to ensure all interfund accounts are reconciled and settled monthly before completing the HUD-52681-B report. Accounting staff will review and verify key line items (including Unrestricted Net Position and Cash in Investments) against the general ledger prior to VMS submission. Supervisory review will be required to confirm accuracy. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.
View Audit 369074
Finding 1156722 (2024-001)
Material Weakness 2024
City of Platteville
WI
Internal Control / Segregation of Duties HUD Housing Programs
Finding #2024-001- Limited Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has co...
Finding #2024-001- Limited Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. All internal control duties can be classified into four broad categories: authorization, custody, recordkeeping, and reconciliation. No one person should have control of two or more of these four categories for any one cycle. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. Currently, there are the following overlapping duties: - Both Accounting Specialists have the authority to enter invoices into the system, print checks, and have access to the electronic signatures. Preferably, the check cutting process would separate the entering of payment information into the system and the ability to print signed checks. - One Accounting Specialist creates deposits and makes deposits with the bank. Although not the standard procedure, the Accounting Specialist has the authority to collect cash receipts. Ideally, separate individuals would collect cash and make deposits. - The Housing Authority Executive Director opens the mail, creates deposits and takes deposits to the bank. The Executive Director also enters invoices into the system and prints checks. The Board of Commissioners approves disbursements and all checks require dual signatures. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Cause: Limited number of personnel. Recommendation: We recommend that the City consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase personnel to bring about a more effective segregation of duties.
View Audit 369068
Finding 1156720 (2024-001)
Material Weakness 2024
Norton Healthcare, Inc. and Affiliates
KY
Allowable Costs / Cost Principles
Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially D...
Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Disaster Grants – Public Assistance of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Company does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the function’s review of unapproved timesheets. Planned corrective action: Norton Healthcare is currently upgrading its timekeeping and attendance system. As part of this initiative, enhanced training and expanded functionality for timekeepers will help ensure that timecards are reviewed and approved prior to payment, in compliance with internal requirements. Relevant policies and procedures will be updated to support this process, including the retention of appropriate documentation. Additionally, the Norton Clinical Agency will establish a formal written policy outlining the stipend review and approval process, ensuring that all documentation is properly maintained. All other expenses submitted to FEMA will be reviewed and approved in writing, outside of the Grants Portal, with appropriate documentation. At this time, there are no pending or anticipated projects related to FEMA claims. Anticipated completion date: December 31, 2026 Responsible contact person: Adam Kempf
View Audit 369066
Finding 1156719 (2024-005)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Equipment & Real Property Management
Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are ...
Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are conducted over property at least once every two years as it pertains to the Program. Management Response: To address this deficiency, the Program and Fixed Asset Accounting teams will collaborate to ensure adherence to the established asset tracking and inventory management procedures. This joint effort will ensure that the subsidiary ledger is accurately maintained, equipment acquired through federal grants is properly recorded, and physical inventories are conducted within the prescribed biennial timelines in compliance with 2 CFR section 200.313(d). Contact Person (s) Responsible for Corrective Action: Steve Baron, Program Manager and Tony Hamric, Fixed Assets Manager. Anticipated Completion Date: December 31, 2025
View Audit 369065
Finding 1156714 (2024-003)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were ...
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156705 (2024-004)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Matching / Level of Effort / Earmarking
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibil...
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibility will be developed. This procedure will include detailed steps and required documentation, supported by a standardized eligibility checklist to guide staff in confirming and accurately recording participant eligibility. Additionally, all program staff involved in intake and eligibility determination will be trained on the new procedure. Contact Person - Responsible for Corrective Action: Elizabeth LaRoy, Program Manager Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156697 (2024-002)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded...
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded and charged to the grant. Management Response: Management will develop and implement written procedures to ensure the timely communication of discrepancies identified during the effort certification process to the Grant Accounting team for appropriate review and adjustment. Program staff will be trained in the new process, and reviews will be conducted to monitor compliance and ensure the continued effectiveness of the process. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director and Venice Northe, Grants Accounting Manager. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156691 (2024-001)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Reporting Matching / Level of Effort / Earmarking
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting document...
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained. As a result, no corrective action will be taken. Contact Person - Responsible for Corrective Action: Jen Agnello, Program Manager Anticipated Completion Date: N/A
View Audit 369065
Finding 1156689 (2024-002)
Material Weakness 2024
Town of Kewanna
IN
Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319
Finding 2024-002 Drinking Water State Revolving Fund - Procurement Contact Person Responsible for Corrective Action: JoAnn Collins/Clerk Treasurer Contact Phone Number and Email Address: 574-653-2112 kewanna@fourway.net Views of Responsible Officials: We concur with the finding Description of Correc...
Finding 2024-002 Drinking Water State Revolving Fund - Procurement Contact Person Responsible for Corrective Action: JoAnn Collins/Clerk Treasurer Contact Phone Number and Email Address: 574-653-2112 kewanna@fourway.net Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We will update our procurement policy and implement a system of internal controls to ensure a purchasing policy is in place and quotes are obtained for small purchases. Anticipated Completion Date: A policy and internal controls will be in place by January 1, 2026
View Audit 369056
Finding 1156688 (2024-002)
Material Weakness 2024
Chief Seattle Club
WA
Procurement, Suspension & Debarment § 200.318 § 200.320
Reporting - Reportable Findings and Questioned Costs for Federal Awards Contact Person Marc Taylor, CFO E-Mail: Marc@chiefseattleclub.org Corrective Action Planned This finding occurred because of a lack of both procurement knowledge and staff oversight over a contractor handling the procurement for...
Reporting - Reportable Findings and Questioned Costs for Federal Awards Contact Person Marc Taylor, CFO E-Mail: Marc@chiefseattleclub.org Corrective Action Planned This finding occurred because of a lack of both procurement knowledge and staff oversight over a contractor handling the procurement for Eagle Village. Thanks to this finding, our real estate team has gained a better understanding of federal procurement requirements. Our auditor provided us with a procurement checklist, which we began using and will ensure that we comply with our procurement policy and better document future procurements. Anticipated Completion Date September 30, 2025
View Audit 369055
Finding 1156687 (2024-004)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Finding 1156686 (2024-003)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Internal Control / Segregation of Duties
Management agrees and will reimburse the employee for the amounts due for hours worked more than 40 hours in a work week during the fiscal year. Management will develop review procedures to respond to this finding.
Management agrees and will reimburse the employee for the amounts due for hours worked more than 40 hours in a work week during the fiscal year. Management will develop review procedures to respond to this finding.
View Audit 369054 Questioned Costs: $1
Finding 1156685 (2024-002)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Finding 1156684 (2024-001)
Material Weakness 2024
Madonna Center, Inc.
TX
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.430
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
View Audit 369054 Questioned Costs: $1
Finding 1156683 (2024-002)
Material Weakness 2024
Housing Authority of the City of Ellijay
GA
HUD Housing Programs Internal Control / Segregation of Duties
2024-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented prior to check issuance. ...
2024-002 Condition: Deficiencies Noted in Cash Disbursements Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. We will review the cash disbursement documentation process in order to ensure that each disbursement is fully documented prior to check issuance. We will further review our internal control procedures and policies over cash disbursements and conduct regular quality control reviews to ensure compliance with HUD regulations. We will implement any needed procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Ms. Linda Dillard, Executive Director Timeframe: As of December 31, 2025
View Audit 369051
Finding 1156682 (2024-001)
Material Weakness 2024
Housing Authority of the City of Ellijay
GA
Procurement, Suspension & Debarment
2024-001 Condition: Deficiencies Noted in Procurement Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. Going forward we will review and follow our procurement policies and HUD guidelines in obtaining and signing contracts so that all contracts are in accor...
2024-001 Condition: Deficiencies Noted in Procurement Steps to resolve: Management agrees with the audit finding and the auditor’s recommendation. Going forward we will review and follow our procurement policies and HUD guidelines in obtaining and signing contracts so that all contracts are in accordance with applicable HUD regulations. We will implement any needed procedures and changes to ensure that this finding will be cleared by the subsequent fiscal year audit. Individual responsible for correction: Ms. Linda Dillard, Executive Director Timeframe: As of December 31, 2025
View Audit 369051
Finding 1156681 (2024-001)
Material Weakness 2024
Town of Upland
IN
Equipment & Real Property Management § 200.303 § 200.313
Finding 2024-001 Finding Subject: Community Development Block Grant Program- Equipment and Real Property Management. Contact Person Responsible for Corrective Action: Mary Fletcher, Clerk-Treasurer Contact Phone Number and Email Address: (765) 998-7439 ext. 1, mfletcher@uplandindiana.com Views of Re...
Finding 2024-001 Finding Subject: Community Development Block Grant Program- Equipment and Real Property Management. Contact Person Responsible for Corrective Action: Mary Fletcher, Clerk-Treasurer Contact Phone Number and Email Address: (765) 998-7439 ext. 1, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding. Correction Action Plan: The Town of Upland will concur with our asset management consultant and have the missing information added to our asset ledger. Anticipated Completion Date: September 30, 2025
View Audit 369047
Finding 1156680 (2024-001)
Material Weakness 2024
Thf San Gabriel Holdings, LLC
TX
Procurement, Suspension & Debarment Subrecipient Monitoring HUD Housing Programs § 200.512
Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8...
Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8100 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2024-001: Comments on the Finding and Each Recommendation: For the year ended December 31, 2023, the Company did not submit the Data Collection Form (SF-SAC) to the Federal Audit Clearinghouse in the time period required by Uniform Guidance Section 2 CFR 200.512. Action(s) taken or planned on the finding: The Data Collection Form was submitted to the Federal Audit Clearinghouse on May 10, 2024 and management will submit the Data Collection Form timely going forward.
View Audit 369043
Finding 1156679 (2024-002)
Material Weakness 2024
Employment Connection
MO
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed mont...
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed monthly review process. This will include verifying payroll charges against supporting documentation such as payroll registers, time records, and allocation spreadsheets. Management will also explore the development of a standardized reconciliation checklist and introduce a secondary review step to ensure accuracy and completeness. These measures, combined with continued monthly oversight by the CFO, are intended to reduce the risk of billing errors due to human oversight and reinforce the reliability of payroll cost allocations. Name of Responsible Person: Nora Davis, Chief Financial Officer Anticipated Completion Date: April 30, 2026
View Audit 369034
Finding 1156668 (2024-003)
Material Weakness 2024
Belmont County
OH
Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.405
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interp...
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS
View Audit 369030 Questioned Costs: $1
Finding 1156667 (2024-006)
Material Weakness 2024
Adams County
OH
Student Financial Aid Allowable Costs / Cost Principles § 200.302
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
View Audit 369025
Finding 1156666 (2024-005)
Material Weakness 2024
Adams County
OH
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Special Tests & Provisions
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
View Audit 369025
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