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Corrective Action Plans

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Finding 1162475 (2024-006)
Material Weakness 2024
HEARTLAND ALLIANCE HEALTH AND SUBSIDIARY
IL
Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now ...
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
View Audit 372215
Finding 1162471 (2024-005)
Material Weakness 2024
HEARTLAND ALLIANCE HEALTH AND SUBSIDIARY
IL
Reporting
Inaccurate and Late Reporting Planned Corrective Action: Regarding underlying support, HAH now utilizes drawdown documentation for all draws; this will provide support for all draws and facilitate submission of accurate and timely SF-425 documentation. Some SF-425 submissions for FY25 will not be su...
Inaccurate and Late Reporting Planned Corrective Action: Regarding underlying support, HAH now utilizes drawdown documentation for all draws; this will provide support for all draws and facilitate submission of accurate and timely SF-425 documentation. Some SF-425 submissions for FY25 will not be submitted timely, because the federal project officer has not approved the budget or because the drawdowns have not been completed; the federal shutdown has exacerbated this circumstance for FY25. As HAH gets caught up with federal drawdowns, HAH expects to be able to submit SF-425 documentation in a timely and accurate fashion. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: April 2026
View Audit 372215
Finding 1162469 (2024-004)
Material Weakness 2024
HEARTLAND ALLIANCE HEALTH AND SUBSIDIARY
IL
Cash Management
Compliance with Cash Management Requirements Planned Corrective Action: Heartland Alliance Health has established a formal Drawdown Policy and Procedure designed to ensure compliance with federal cash management regulations and to prevent premature or excessive drawdowns of grant funds. The policy i...
Compliance with Cash Management Requirements Planned Corrective Action: Heartland Alliance Health has established a formal Drawdown Policy and Procedure designed to ensure compliance with federal cash management regulations and to prevent premature or excessive drawdowns of grant funds. The policy includes specific requirements for timing, documentation, reconciliation of expenditures to draw requests, and internal approvals prior to submission. The Drawdown Policy and Procedure was reviewed and approved by the Board of Directors in October 2025. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
View Audit 372215
Finding 1162468 (2024-003)
Material Weakness 2024
HEARTLAND ALLIANCE HEALTH AND SUBSIDIARY
IL
HUD Housing Programs Material Weakness
Reasonable Rent Review Planned Corrective Action: The Continuum of Care (CoC) program was transitioned to another organization during FY2024 as part of a broader realignment of programs and services. Heartland Alliance Health no longer administers this program, and all compliance responsibilities, i...
Reasonable Rent Review Planned Corrective Action: The Continuum of Care (CoC) program was transitioned to another organization during FY2024 as part of a broader realignment of programs and services. Heartland Alliance Health no longer administers this program, and all compliance responsibilities, including tenant files and rent documentation, were transferred to the receiving entity. At the request of the auditors, Heartland Alliance Health has initiated contact with the new organization to confirm that all required program and tenant records have been properly transferred, secured, and maintained in compliance with HUD regulations. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
View Audit 372215
Finding 1162454 (2024-007)
Material Weakness 2024
Independent School District No. 622
MN
Reporting § 200.512
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2024-007 - Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (S...
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2024-007 - Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEFA) and federal reporting package to be submitted to the federal audit clearinghouse within the earlier of 30 calendar days after the receipt of the auditor’s report(s), or 9 months after the end of the audit period. Condition – The District’s audited SEFA and federal reporting package for the fiscal year ended June 30, 2024, were not submitted to the federal audit clearinghouse within nine months after the end of the audit period. Corrective Action Plan Actions Planned – The completion of the District’s audited annual financial statements for the year ended June 30, 2024, which is a required component of the federal reporting package, was delayed beyond the nine-month deadline, primarily due to turnover in the District’s finance department. District management will ensure that all information required to comply with federal reporting requirements will be completed and submitted in a timely manner going forward. Official Responsible – Josh Anderson, the District’s Director of Finance. Planned Completion Date – December 31, 2025. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Josh Anderson, the District’s Director of Finance, will monitor the year‑end financial closing and reporting process to ensure all federal and state reporting requirements are complied with in the future.
View Audit 372214
Finding 1162429 (2024-002)
Material Weakness 2024
National Council on Radiation Protection and Measurements
MD
Reporting Significant Deficiency
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
View Audit 372211
Finding 1162424 (2024-002)
Material Weakness 2024
New Hope Development Services, Inc.
IN
New Hope Development Services, Inc. is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
New Hope Development Services, Inc. is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
View Audit 372210
Finding 1162423 (2024-001)
Material Weakness 2024
New Hope Development Services, Inc.
IN
The Organization accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will maintain signed income certifications for all tenants in accordance with HUD guidelines to ensure proper documentation is maintained in tenant files.
The Organization accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will maintain signed income certifications for all tenants in accordance with HUD guidelines to ensure proper documentation is maintained in tenant files.
View Audit 372210
Finding 1162422 (2024-001)
Material Weakness 2024
New Hope Services, INC
IN
New Hope Services, Inc. and Subsidiary is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
New Hope Services, Inc. and Subsidiary is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
View Audit 372209
Finding 1162421 (2024-002)
Material Weakness 2024
Cincinnati Health Network, Inc.
OH
Procurement, Suspension & Debarment § 200.319 § 200.320
Condition: The organization intended to use a competitive proposal process to procure a van. However, it failed to publicly advertise the request for proposals, limiting the pool of potential vendors to only those known to the organization. Additionally, the request for proposals did not include a c...
Condition: The organization intended to use a competitive proposal process to procure a van. However, it failed to publicly advertise the request for proposals, limiting the pool of potential vendors to only those known to the organization. Additionally, the request for proposals did not include a complete and accurate list of specifications, nor did it include the evaluation and selection criteria that would be used to assess the proposals. While the organization did obtain three proposals and documented its rationale for selecting a vendor that was not the lowest bidder, the overall process did not meet the standards for full and open competition required by federal regulations. Corrective Action Plan: To address this, we are committing to develop and implement a comprehensive procurement policy and procedures manual that strictly aligns with requirements within the Uniform Guidance. This manual will include detailed checklists for all procurement methods, covering public advertising, clear specification development, and the use of pre-established, documented evaluation criteria, followed by mandatory training for all staff involved in procurement. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025
View Audit 372206
Finding 1162420 (2024-001)
Material Weakness 2024
Cincinnati Health Network, Inc.
OH
Questioned Costs Cash Management § 200.302 § 200.305 § 200.333
Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount tr...
Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025
View Audit 372206 Questioned Costs: $1
Finding 1162415 (2024-002)
Material Weakness 2024
City of Fellsmere
FL
Procurement, Suspension & Debarment § 200.303
2024-002 Suspension and Debarment Recommendation: The City should perform SAM checks for all vendors or contractors prior to entering into covered transactions and retain documentation of these processes. Management Response: Management concurs with the recommendation. The City recognizes the import...
2024-002 Suspension and Debarment Recommendation: The City should perform SAM checks for all vendors or contractors prior to entering into covered transactions and retain documentation of these processes. Management Response: Management concurs with the recommendation. The City recognizes the importance of complying with 2 CFR 180.300 and 2 CFR 200.303 to ensure that vendors and contractors are not suspended, debarred, or otherwise excluded from participation in federally funded programs. To strengthen compliance and documentation going forward, the City will implement the following corrective actions: 1. Establish a Standardized SAM Verification Process: The City will formalize written procedures requiring verification of all vendors and contractors in the System for Award Management (SAM) prior to entering into any covered transaction. 2. Maintain Documentation: Copies or screenshots of SAM verifications will be retained in the vendor file and/or attached within the City’s financial management system to ensure documentation is readily available for audit purposes. 3. Designate Responsibility: The Finance Department will assign a staff member to perform and document the SAM verification process, with supervisory review prior to vendor approval. 4. Provide Staff Training: Relevant staff will receive training on federal procurement requirements, including SAM verification procedures and documentation standards. 5. Ongoing Monitoring: Management will periodically review vendor files to confirm compliance with these requirements and ensure documentation is properly maintained. Management expects these measures will strengthen internal controls, ensure continued compliance with federal regulations, and prevent similar documentation issues in future audits. The responsible party is Carolina Rodriguez, Grants Coordinator. The findings will be corrected by December 2025.
View Audit 372195
Finding 1162414 (2024-003)
Material Weakness 2024
Community Housing Partnership
CA
Significant Deficiency Internal Control / Segregation of Duties
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.
View Audit 372194
Finding 1162411 (2024-001)
Material Weakness 2024
Inova Health System
VA
Questioned Costs Subrecipient Monitoring Cash Management
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project...
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193 Questioned Costs: $1
Finding 1162410 (2024-002)
Material Weakness 2024
Inova Health System
VA
Subrecipient Monitoring Eligibility Reporting
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193
Finding 1162404 (2024-001)
Material Weakness 2024
Community Human Services
CA
Questioned Costs Procurement, Suspension & Debarment
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
View Audit 372187 Questioned Costs: $1
Finding 1162402 (2024-001)
Material Weakness 2024
Kootasca Community Action, Inc.
MN
Reporting § 200.512
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtainin...
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtaining necessary documentation for audit completion. Effect: Late submission of the audit package constitutes noncompliance with federal requirements. Corrective Action Taken: Management will work to meet audit deadlines and assign responsibilities for timely submission. Responsible Party: Marta Carrigan, Executive Director Anticipated Completion Date: September 30, 2026
View Audit 372181
Finding 1162375 (2024-004)
Material Weakness 2024
Golden Valley County
ND
Contact Person Tamra Sperry, Auditor Corrective Action Plan The County will ensure records are reconciled and available for audit within a timely manner of year end. Planned Completion Date for CAP Ongoing
Contact Person Tamra Sperry, Auditor Corrective Action Plan The County will ensure records are reconciled and available for audit within a timely manner of year end. Planned Completion Date for CAP Ongoing
View Audit 372178
Finding 1162368 (2024-006)
Material Weakness 2024
Housing Authority of the City of Newark
NJ
Questioned Costs Eligibility HUD Housing Programs
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Execu...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing Program to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175 Questioned Costs: $1
Finding 1162367 (2024-005)
Material Weakness 2024
Housing Authority of the City of Newark
NJ
HUD Housing Programs Special Tests & Provisions
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175
Finding 1162366 (2024-004)
Material Weakness 2024
Housing Authority of the City of Newark
NJ
HUD Housing Programs Special Tests & Provisions
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175
Finding 1162365 (2024-003)
Material Weakness 2024
Housing Authority of the City of Newark
NJ
HUD Housing Programs
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Direc...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 372175
Finding 1162355 (2024-001)
Material Weakness 2024
GENTRY COUNTY, MISSOURI
MO
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.510
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
View Audit 372164
Finding 1162353 (2024-002)
Material Weakness 2024
Allen County
OH
Subrecipient Monitoring Allowable Costs / Cost Principles Period of Performance § 200.329
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Report...
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Reports are expected to be filed correctly and timely, with future education being sought as needed.
View Audit 372159
Finding 1162350 (2024-001)
Material Weakness 2024
Allen County
OH
Subrecipient Monitoring Reporting § 200.328
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. ...
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. The Director reports several calendaring mechanisms are in place and the reports are being tracked by duplicative methods since that error.
View Audit 372159
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