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Corrective Action Plans

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Finding 1152909 (2024-001)
Material Weakness 2024
Prime Healthcare Foundation, Inc. and Subsidiaries
CA
Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.319
We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the fed...
We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.
View Audit 366228 Questioned Costs: $1
Finding 1152908 (2024-004)
Material Weakness 2024
Wildberry Manor Project of Community Housing, Inc.
IA
Matching / Level of Effort / Earmarking
Recommendation: All reports should be timely filed to ensure proper loan payments. Action taken: The Corporation is aware of the delinequency. There has been a change in personnel to help ensure tha ttimely filed reports are made. Anticipated Date of Completion: December 31, 2025.
Recommendation: All reports should be timely filed to ensure proper loan payments. Action taken: The Corporation is aware of the delinequency. There has been a change in personnel to help ensure tha ttimely filed reports are made. Anticipated Date of Completion: December 31, 2025.
View Audit 366227
Finding 1152906 (2024-003)
Material Weakness 2024
Wildberry Manor Project of Community Housing, Inc.
IA
Reporting Internal Control / Segregation of Duties
Recommendation: We recommend that management establish internal procedures to identify potential material misstatements and make adjustments if needed prior to providing the independent auditor with the trial balance for the period being audited. Action Taken: Prior to closing out the year-end books...
Recommendation: We recommend that management establish internal procedures to identify potential material misstatements and make adjustments if needed prior to providing the independent auditor with the trial balance for the period being audited. Action Taken: Prior to closing out the year-end books, the accounts will be looked at and any needed adjustments will be made. Anticipated Date of Completion: December 31, 2025
View Audit 366227
Finding 1152905 (2024-002)
Material Weakness 2024
Wildberry Manor Project of Community Housing, Inc.
IA
Reporting Internal Control / Segregation of Duties
Recommendation: We realize that obtaining the expertise necessary to prepare the financial statements, including all necessary disclosures, in accordance with GAAP can be considered costly and ineffective. However, obtaining additional GAAP knowledge through reading relevant accounting literature an...
Recommendation: We realize that obtaining the expertise necessary to prepare the financial statements, including all necessary disclosures, in accordance with GAAP can be considered costly and ineffective. However, obtaining additional GAAP knowledge through reading relevant accounting literature and attending continuing education courses should help management improve in their ability to prepare internally and take responsibility for reliable GAAP financial statements. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: December 31, 2025
View Audit 366227
Finding 1152904 (2024-001)
Material Weakness 2024
Wildberry Manor Project of Community Housing, Inc.
IA
Internal Control / Segregation of Duties Reporting
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will impl...
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional controls where possible. Anticipated Date of Completion: December 31, 2025
View Audit 366227
Finding 1152893 (2024-004)
Material Weakness 2024
Vinton County
OH
Eligibility School Nutrition Programs Matching / Level of Effort / Earmarking § 200.303
The Board of Health WIC personnel will implement additional control practices for the review and approval for WIC eligibility for participants. In addition, WIC personnel will ensure all supporting documentation has been obtained in order to determine participant eligibility.
The Board of Health WIC personnel will implement additional control practices for the review and approval for WIC eligibility for participants. In addition, WIC personnel will ensure all supporting documentation has been obtained in order to determine participant eligibility.
View Audit 366220
Finding 1152891 (2024-003)
Material Weakness 2024
Vinton County
OH
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
The Board of Health will ensure the Health Department is properly implementing their internal control policies and ensure all timecards are signed by the employee and supervisor to indicate timesheets are accurate. These signed timecards will be maintained for audit.
The Board of Health will ensure the Health Department is properly implementing their internal control policies and ensure all timecards are signed by the employee and supervisor to indicate timesheets are accurate. These signed timecards will be maintained for audit.
View Audit 366220
Finding 1152889 (2024-002)
Material Weakness 2024
Vinton County
OH
Allowable Costs / Cost Principles Procurement, Suspension & Debarment Cash Management § 200.302 § 200.305 § 200.318 § 200.320 § 200.320(B)
The Board of Health will adopt updated written policies periodically in accordance with the Uniform Guidance to help improve internal controls over federal compliance for the findings listed in this number.
The Board of Health will adopt updated written policies periodically in accordance with the Uniform Guidance to help improve internal controls over federal compliance for the findings listed in this number.
View Audit 366220
Finding 576340 (2024-002)
Significant Deficiency 2024
Community Directions, Inc.
LA
HUD Housing Programs Cash Management Special Tests & Provisions
FINDING #2024-002 RESERVE FOR REPLACEMENT Condition: The Reserve for Replacement account balance for Park Ridge Apartments, Phase 4 was underfunded in the amount of $750 at December 31, 2023. The entity made an additional payment of $650 during the year, leaving a balance of $125 underfunded at D...
FINDING #2024-002 RESERVE FOR REPLACEMENT Condition: The Reserve for Replacement account balance for Park Ridge Apartments, Phase 4 was underfunded in the amount of $750 at December 31, 2023. The entity made an additional payment of $650 during the year, leaving a balance of $125 underfunded at December 31, 2024. Recommendation: The management agent should ensure that all required deposits are made to the Reserve for Replacement account and that the balance in that account meets the minimum required balance in accordance with the regulatory agreement between the Entity and HUD. View of Responsible Officials and Planned Corrective Action: The management agent agrees with the finding and the auditor’s recommendations have been adopted.
View Audit 366207
Finding 576338 (2024-001)
Significant Deficiency 2024
Community Directions, Inc.
LA
HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties
FINDING #2024-001 SURPLUS CASH Condition: At December 31, 2022 the Entity had surplus cash totaling $9,162, due to Home Funds. Park Ridge Apartments, Phase 3 had surplus cash in the amount of $4,000. Park Ridge Apartments, Phase 4 had surplus cash in the amount of $2,077. Park Ridge Apartments, P...
FINDING #2024-001 SURPLUS CASH Condition: At December 31, 2022 the Entity had surplus cash totaling $9,162, due to Home Funds. Park Ridge Apartments, Phase 3 had surplus cash in the amount of $4,000. Park Ridge Apartments, Phase 4 had surplus cash in the amount of $2,077. Park Ridge Apartments, Phase 5 had surplus cash in the amount of $1,379. Parsk Ridge Apartments, Phase 6 had surplus cash in the amount of $1,706. The Entity paid the surplus cash for Park Ridge Apartments, Phase 3 and Phase 6, leaving a balance of $3,456 at December 31, 2024. Recommendation: The management agent should compute an estimate of surplus cash for the fiscal year upon completion of that period. In the event that surplus cash exists at the completion of the fiscal period, the management agent should make an installment payment on the HOME note. Views of Responsible Officials and Planned Corrective Action: The management agent agrees with the finding and the auditor’s recommendations have been adopted. Surplus cash will be calculated upon the completion of an annual fiscal period. If it is concluded that surplus cash exists at the end of the annual fiscal period, an installment payment will be made on the loan.
View Audit 366207
City of Fort Lauderdale
FL
Subrecipient Monitoring Cash Management HUD Housing Programs
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.
View Audit 366205
Finding 576336 (2024-001)
Significant Deficiency 2024
City of Fort Lauderdale
FL
Subrecipient Monitoring Cash Management HUD Housing Programs § 200.303 § 200.328
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.
View Audit 366205
Greensboro College, Inc. and Affiliates
NC
Student Financial Aid Reporting Matching / Level of Effort / Earmarking
Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in ...
Contact Person: Travis Mickey, Registrar Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College will collaborate with NSC to evaluate the errors in the file transmissions and to develop procedures to minimize further errors in the future. More specifically, the College will review the reporting procedures for withdrawn and graduating students to ensure the correct information is transmitted to NSLDS. Anticipated Completion Date: 6/30/2025
View Audit 366195
Finding 576323 (2024-001)
Significant Deficiency 2024
Greensboro College, Inc. and Affiliates
NC
Special Tests & Provisions
Contact Person: Regina Elliott, Chief Information Officer Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College updated and implemented a comprehensive information security program on 1/19/25 that meets all requirements. And w...
Contact Person: Regina Elliott, Chief Information Officer Views of Responsible Officials and Planned Corrective Action: There is no disagreement with the audit finding. The College updated and implemented a comprehensive information security program on 1/19/25 that meets all requirements. And we will continue to review and update our IT policies and procedures on a regular basis. Furthermore, the College has strengthened our internal controls in order to ensure we are aware of new regulatory requirements and enhance our process for addressing them in a timely manner. Anticipated Completion Date: 1/19/2025
View Audit 366195
Finding 576322 (2024-002)
Material Weakness 2024
Pro Viviendas Iv, Inc.
PR
HUD Housing Programs Material Weakness Special Tests & Provisions
Contact Person: Carmen G. Rivera Proposed Completion Date: June 30,2025 Corrective Action: Management has consulted with HUD’s account executive regarding the use of the reserves as collateral for financing. As of this date, Management is still waiting for HUD’s response since they are analyzing t...
Contact Person: Carmen G. Rivera Proposed Completion Date: June 30,2025 Corrective Action: Management has consulted with HUD’s account executive regarding the use of the reserves as collateral for financing. As of this date, Management is still waiting for HUD’s response since they are analyzing the transaction. Banco Popular de Puerto Rico, the mortgage, will be notified about HUD final notification to ensure the correct collateral requirements are met. Evidence of resolution will be sent to HUD. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Vice-President. The estimated completion date for the finding is June 30, 2025.
View Audit 366194
Finding 576321 (2024-001)
Significant Deficiency 2024
Pro Viviendas Iv, Inc.
PR
HUD Housing Programs Cash Management
Finding No. 2024–001 - REPLACEMENT RESERVE DEPOSITS Contact Peron: Carmen G. Rivera Proposed Completion Date: Resolved Corrective Action: Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
Finding No. 2024–001 - REPLACEMENT RESERVE DEPOSITS Contact Peron: Carmen G. Rivera Proposed Completion Date: Resolved Corrective Action: Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
View Audit 366194
Finding 576320 (2024-001)
Significant Deficiency 2024
Washington Association of Sheriffs and Police Chiefs
WA
Subrecipient Monitoring § 200.332
Finding Number 2024-001 Contact Person(s): Kim Goodman, Finance Director Corrective action planned: The Association acknowledges the audit findings and recognizes the importance of strengthing internal control processes to ensure staff understand the nature of a subrecipient vs a contractor, and t...
Finding Number 2024-001 Contact Person(s): Kim Goodman, Finance Director Corrective action planned: The Association acknowledges the audit findings and recognizes the importance of strengthing internal control processes to ensure staff understand the nature of a subrecipient vs a contractor, and that they ensure that this determination is being reviewed, and clearly communicated in underlying agreements, as part of their internal control processes. The following corrective actions have been taken: • All 23-25 AJA Grantees will be provided agreements with the correct designation of "sub recipient." • All 25-27 AJA and MHFR Grantees will have the designation of "sub recipient." Anticipated completion date: Completed June 30, 2025
View Audit 366192
Finding 576316 (2024-001)
Material Weakness 2024
Rockland Community College
NY
Subrecipient Monitoring Reporting Equipment & Real Property Management
Corrective Action Plan: In response to the findings related to the Gramm-Leach-Bliley Act (GLBA) Safeguards Rule compliance at [Institution Name], we have developed the following Corrective Action Plan to address identified deficiencies and strengthen our information security program. • Corrective A...
Corrective Action Plan: In response to the findings related to the Gramm-Leach-Bliley Act (GLBA) Safeguards Rule compliance at [Institution Name], we have developed the following Corrective Action Plan to address identified deficiencies and strengthen our information security program. • Corrective Action: By December 31, 2025, Rockland Community College will complete a comprehensive risk assessment of all systems handling covered financial and student information. Risk assessments will be conducted annually thereafter, with updates documented and reviewed by the Information Security Officer (ISO). • Corrective Action: A revised Written Information Security Program (WISP) will be finalized by July 31, 2026. It will outline administrative, technical, and physical safeguards, as well as roles and responsibilities for maintaining compliance. • Corrective Action: A Qualified Individual responsible for overseeing and enforcing the Safeguards Rule compliance program will be designated by December 31, 2025. • Corrective Action: All vendor agreements will be reviewed and updated by July 31, 2026, to include language requiring providers to safeguard covered data. A vendor management procedure will also be implemented to ensure ongoing oversight. • An annual GLBA training program will be implemented starting July 31, 2026. Training completion will be monitored and documented through the HR compliance system. • Corrective Action: Rockland Community College will implement quarterly testing of safeguards and document results. Findings will be reported to the Executive Cabinet and used to continuously improve protections. All corrective actions will be completed by August 31, 2026. Progress will be tracked by the Information Security Officer and reported quarterly to the Executive Cabinet and the Board of Trustees. We are committed to protecting sensitive financial and student information and ensuring full compliance with the GLBA Safeguards Rule. Please let us know if additional information is required.
View Audit 366191
Finding 576315 (2024-001)
Significant Deficiency 2024
Affiliated Tribes of Northwest Indians
OR
Reporting
Environmental Protection Agency Affiliated Tribes of Northwest Indians (ATNI) respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024, to December 31, 2024 FINDINGS AND QUESTIONED COSTS—MAJOR FEDERAL PROGRAM 2024-001 – Significant...
Environmental Protection Agency Affiliated Tribes of Northwest Indians (ATNI) respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024, to December 31, 2024 FINDINGS AND QUESTIONED COSTS—MAJOR FEDERAL PROGRAM 2024-001 – Significant Deficiency in Internal Control over Compliance – Reporting Recommendation: We recommend ATNI updates the grant policies and procedures to include a documented review procedure. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has implemented new procedures to ensure the review of program reports are sufficiently documented. This included drafting a new Grant Management Policy and Grant Procedures Manual, which will be approved by the Board of Directors in September 2025. Name of person responsible for the corrective action plan: Amber Schultz-Oliver, Executive Director. Contact: ambers@atnitribes.org Planned completion date for the corrective action plan: New procedures have been implemented as of August 30, 2025.
View Audit 366189
Finding 576314 (2024-004)
Significant Deficiency 2024
Yakama Nation Housing Authority
WA
HUD Housing Programs Material Weakness Significant Deficiency § 200.303
Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a policy and procedures to address environmental reviews and ensure that when an environmental review is required that it is conducted and approved prior to beginning work...
Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a policy and procedures to address environmental reviews and ensure that when an environmental review is required that it is conducted and approved prior to beginning work on a project. Estimated Completion Date: October 1, 2025
View Audit 366187
Finding 576313 (2024-003)
Significant Deficiency 2024
Yakama Nation Housing Authority
WA
Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.326
Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a suspension and debarment training for all staff and program managers to ensure that suspension and debarment requirements are adhered to and include a search on Sam.gov,...
Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a suspension and debarment training for all staff and program managers to ensure that suspension and debarment requirements are adhered to and include a search on Sam.gov, as required. Estimated Completion Date: October 31, 2025
View Audit 366187
Finding 576312 (2024-002)
Material Weakness 2024
Yakama Nation Housing Authority
WA
Allowable Costs / Cost Principles Eligibility HUD Housing Programs § 200.303
Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process an...
Persons responsible for this corrective action plan: Phylistine Alexander, Housing Manager and Jana Kent, Executive Director Corrective Action Plan: YNHA will work with the NwONAP Grant Evaluation Director to evaluate our current tenant file documentation and eligibility determination process and will implement recommendations from HUD. Estimated Completion Date: December 31, 2025
View Audit 366187
North Mississippi Priamry Health Care INC
MS
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512
2024-003 a. Contact person responsible for corrective action: Steve Reed, Chief Financial Officer b. Description of corrective action to be taken: Management has implemented a staffing plan, established an audit preparation calendar, and added monitoring controls to ensure timely completion of f...
2024-003 a. Contact person responsible for corrective action: Steve Reed, Chief Financial Officer b. Description of corrective action to be taken: Management has implemented a staffing plan, established an audit preparation calendar, and added monitoring controls to ensure timely completion of financial statement audits and submission of the Data Collection Form. The CFO is responsible for oversight, and these procedures were put in place beginning September 2025 to prevent recurrence. c. Anticipated completion date of corrective action: Ongoing.
View Audit 366168
Finding 576246 (2024-001)
Significant Deficiency 2024
Fayette County Airport Authority
PA
Internal Control / Segregation of Duties
The Authority acknowledges that the lack of segregation of duties is present. The Board plans to utilize additional board members in day-to-day involvement. The Airport Manager, John Neckerauer, acknowledges this finding and accepts responsibility in overseeing the addressing of the matter. In addit...
The Authority acknowledges that the lack of segregation of duties is present. The Board plans to utilize additional board members in day-to-day involvement. The Airport Manager, John Neckerauer, acknowledges this finding and accepts responsibility in overseeing the addressing of the matter. In addition to this, the Board will ensure oversight of the operations of the Authority during 2025, in order to mitigate the risk associated with the lack of segregation of duties.
View Audit 366161
Finding 576245 (2024-004)
Significant Deficiency 2024
Opening Doors, Inc.
CA
Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.329
Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the ...
Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the finding. ODI has a process for monitoring activities under Federal awards: Program Managers and Directors are responsible for monitoring activities under Federal awards, with the support of the Agency’s Compliance Specialist. The Agency tracks comparisons of program accomplishments to program objectives and reports these data to grantors as required and, where necessary, communicates significant development to the Federal agency and/or pass-through entity. Corrective Action: Establish comprehensive guidelines to retain documentation of quality control and review for programmatic reports through electronic approvals via email and/or approved tracked changes or review notes within software platforms demonstrating review and approval. Responsible Personnel: Jessie Mabry, CEO; Jeremy Huynh, Compliance Specialist Implementation Date: Immediate implementation to assess tracking methods for Federal programmatic reports, and to develop written guidelines for documenting programmatic report quality control.
View Audit 366160
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