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Eligibility Housing Voucher Cluster Other matter required to be reported in accordance with 2 CFR 200.516(a) Condition: Out of an approximate population of approximately 600 tenants, 40 tenant files were tested and the following deficiencies were noted: ▪ Four files did not have an inspection perfor...
Eligibility Housing Voucher Cluster Other matter required to be reported in accordance with 2 CFR 200.516(a) Condition: Out of an approximate population of approximately 600 tenants, 40 tenant files were tested and the following deficiencies were noted: ▪ Four files did not have an inspection performed during the required period, ▪ Two files did not have an up to date 9886 form on file ▪ One file did not have ID for an adult tenant in the household, and ▪ One file had the incorrect income calculated, which did not impact the HAP received. Auditor Recommendations: The Authority should re-evaluate their established procedures and controls in place to ensure full compliance in regards to eligibility. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor’s sample. Action Taken: Action Due Date Responsible Person Conduct a review of cases associated with inspectionrelated findings to verify the accuracy of the determinations and implement corrections as necessary. In certain cases, inspections may align with approved biennial inspection schedules, or delays may have occurred due to inability to access the unit or tenant non-compliance. In such instances, cases may currently be progressing through the ineligibility process, which requires additional time to resolve in accordance with program requirements. Additionally, the agency identified system-related reporting issues within Yardi that may have impacted the September 30, 2026 Program Manager, Nat Dybens accuracy of inspection tracking reports. The agency has been actively collaborating with system coordinators to address and resolve these issues. Files identified as lacking an upto-date Form HUD-9886 will be reviewed to confirm the accuracy of the finding, and all required documentation will be obtained and maintained in the tenant file to ensure compliance. Form HUD-9886-A [24 CFR 5.230(b)(1), b(2), (c)(4), and (c)(5)]; Notice PIH 2023-27 All adult applicants and participants sign form HUD-9886- A, Authorization for Release of Information. All adult family members (and the head and spouse/cohead, regardless of age) are required to sign the Form HUD9886-A at admission. Participants, prior to January 1, 2024, signed and submitted Form HUD9886 at each annual reexamination. HOTMA eliminated this requirement and instead required that the Form HUD-9886-A be signed only once. On or after January 1, 2024 (regardless of the PHA’s HOTMA compliance date), current program participants must sign and submit a new Form HUD-9886-A at their next interim or annual reexamination. This form will only be signed once. Another Form HUD-9886-A will not be submitted to the PHA except under the following circumstances: • When any person 18 years or older becomes a member of the family; • When a current member of the family turns 18; or • As required by HUD or the PHA in administrative instructions. September 30, 2026 Program Manager, Christi Champ The PHA has the discretion to establish policies around when family members must sign consent forms when they turn 18. PHAs must establish these policies stating when family members will be required to sign consent forms at intervals other than at reexamination. PHA To address areas of identified findings, the agency will reinforce expectations through staff reminders and provide additional training as needed. Additionally, beginning in March 2026, the agency initiated comprehensive refresher trainings for all Housing Specialist (HS) staff, covering core program functions and requirements. These trainings are scheduled for completion by the end of July 2026. Continued throughout the year. Program Manager, Christi Champ and Program Manager, Nat Dybens The file identified as missing required identification documentation for an adult household member will be reviewed to verify the accuracy of the finding, and all necessary documentation will be obtained and updated as appropriate. The agency recognizes that there are multiple acceptable methods for verifying adult identity and will ensure that documentation on file meets HUD requirements and is properly maintained. Additionally, a recertification checklist was implemented in October 2025 to support staff in verifying the presence of all required permanent documentation, including identification, during case file reviews. This control strengthens ongoing compliance and reduces September 30, 2026 Program Manager, Christi Champ the likelihood of similar deficiencies.
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash swe...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash sweep general fund to a separate bookkeeping account. The Hospital had excess cash available to cover the required reserve amount for the fiscal year. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will fund the reserve account from the cash sweep general fund and will monitor the separate bookkeeping account throughout the year to ensure the reserve is properly funded throughout the year as required by the loan documents. Anticipated Completion Date: June 30, 2026
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of fe...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Management requested the auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the drafted schedule of expenditures of federal awards, and we have reviewed with and agree with the final Schedule of Expenditures of Federal Awards. Anticipated Completion Date: Ongoing
Finding 2025-001- Material Weakness related to Procurement and Suspension and Debarment Information on the federal program: Federal Agency: Department of Health and Human Services, Department of Homeland Security, Department of Defense, Department of Justice, National Science Foundation, Department ...
Finding 2025-001- Material Weakness related to Procurement and Suspension and Debarment Information on the federal program: Federal Agency: Department of Health and Human Services, Department of Homeland Security, Department of Defense, Department of Justice, National Science Foundation, Department of Agriculture, US Agency for International Development Program Name: Research and Development Cluster Assistance Listing Number: Various Planned corrective action: The Medical Center has updated the reporting logic of the vendor report submitted to the third-party service provider for suspension and debarment evaluation. The Medical Center has also implemented an internal control where a member of Research Finance management will review the vendor report for accuracy and completeness and sign-off prior to submitting to the third-party service provider for suspension and debarment evaluation. Name of responsible official: Michael Brennan Director, Research Finance Michael.Brennan@childrens.harvard.edu Anticipated completion date: May 11, 2026
EWP Business office Procedure Manual was updated effective 2025 and was submitted to DHHS in March of 2026. Current Procedures is as follows: Business office Procedures. The following procedures will be applied, to the extent that they do no conflict with or contradict the board policies listed abov...
EWP Business office Procedure Manual was updated effective 2025 and was submitted to DHHS in March of 2026. Current Procedures is as follows: Business office Procedures. The following procedures will be applied, to the extent that they do no conflict with or contradict the board policies listed above: 1. Costs will be charged to an award only if the obligation was incurred during the funding period (unless pre-approval by the Federal awarding agency or pass-through grantor agency). 2. All obligations will be liquidated not later than 30 days after the end of the funding period (or specficied by program legislation). 3. Compliance with period of performance requirements will initially be assigned to the individual approving the allowability of the expense/payment. This will be subject to review and approval in the business office as part of the payment processing.
Written Policies Required by the Uniform Guidance Auditor Description of Criteria, Condition, and Effect: The Uniform Guidance requires a non-federal entity that has expended federal awards for a grant awarded on or after December 26, 2014 to have written policies pertaining to: 1) Payments (draws o...
Written Policies Required by the Uniform Guidance Auditor Description of Criteria, Condition, and Effect: The Uniform Guidance requires a non-federal entity that has expended federal awards for a grant awarded on or after December 26, 2014 to have written policies pertaining to: 1) Payments (draws of federal funds and how to minimize the time lapsing between the receipt of federal funds and the disbursement to contractors/employees/subrecipients) (§200.302(6)); 2) Allowability of costs charged to federal programs (§200.302(7)); and 3) Compensation (personnel and benefits policy) (§200.430 and §200.431). Although the Township has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of this condition, the Township did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation: We are aware that the Township is evaluating options using internal and external resources to take corrective action. We recommend that the Township proceed with its selected option as soon as practical, but no later than the end of the next fiscal year. Corrective Action: As noted in the auditor recommendation, the Township is in the process of evaluating a draft grant administration policy, which will address items #1 and #2 (payments and allowability of costs charged to federal programs). Item #3 (compensation) will be addressed via review and modification as needed of the Township’s personnel manual to ensure compliance. Responsible Persons: Karen Trombley, Accounting Coordinator; Sarah Mistretta, Human Resources Director Anticipated Completion Date: December 31, 2026
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a m...
Noncompliance with Grant Reporting Frequency Requirements Auditor Description of Criteria, Condition, and Effect: Per the grant agreement for funds received from the Michigan Department of Environment, Great Lake, and Energy ("EGLE") the Township is required to submit financial status reports on a monthly basis, but instead submitted their reports on a quarterly basis. The Township failed to file financial status reports as required by the Township's grant agreement with EGLE. As a result of this condition, the Township did not comply fully with the reporting requirements under this federal award. Auditor Recommendation: We recommend that the Township review its procedures for compiling financial data for external reporting purposes and develop a calendar by which grant managers and Township administration are notified of pending due dates. Financial reports should be supported by general ledger reports (which should be retained internally along with a copy of the report) and subjected to review and approval by an independent employee or administrator prior to submission. Corrective Action: The Township will strive to submit required reports to EGLE on a monthly basis as required. Expectation will be established via the grant calendar for this grant to be established as noted in finding 2025-001. Responsible Person: Karen Trombley, Accounting Coordinator Anticipated Completion Date: December 31, 2026
Failure to File Required Federal Financial Reports (SF-425) Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to report periodically on financial information, as specified by the 2 CFR 200 Compliance Supplement or grant agreement. Reported information ...
Failure to File Required Federal Financial Reports (SF-425) Auditor Description of Criteria, Condition, and Effect: Recipients of federal awards are required to report periodically on financial information, as specified by the 2 CFR 200 Compliance Supplement or grant agreement. Reported information should be supported by the entity’s accounting records and subjected to an independent review and approval prior to submission in order to detect and correct any errors or omissions. The Township failed to file the semi-annual SF-425 reports as required by the Township's grant agreement with the U.S. Environmental Protection Agency. As a result of this condition, the Township did not comply fully with the reporting requirements under this federal award. Auditor Recommendation: We recommend that the Township review its procedures for compiling financial data for external reporting purposes and develop a calendar by which grant managers and Township administration are notified of pending due dates. Financial reports should be supported by general ledger reports (which should be retained internally along with a copy of the report) and subjected to review and approval by an independent employee or administrator prior to submission. Corrective Action: We have notified the Department of Public Services, who has since had the SF-425’s that were not submitted filed with the EPA. Additionally, the Township’s finance department will produce a grant management calendar as recommended with all Township federal and state external reporting deadlines. Responsible Person: Karen Trombley, Accounting Coordinator Anticipated Completion Date: December 31, 2026
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. HHA has immed...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. HHA has immediately instituted steps to properly abate rents should a unit fail after the 30-day compliance period. Marc A. Recko, Executive Director was designated to be responsible for implementing this corrective action by September 30, 2026.
Authority's Response and Planned Corrective Action: The Authority acknowledges the deficiencies identified in the Section 8 Housing Choice Vouchers program and has implemented internal control procedures to ensure compliance with federal regulations. The Auditor selected two files out of 17 leased u...
Authority's Response and Planned Corrective Action: The Authority acknowledges the deficiencies identified in the Section 8 Housing Choice Vouchers program and has implemented internal control procedures to ensure compliance with federal regulations. The Auditor selected two files out of 17 leased units in the Audit period. In one, the Rent Reasonableness verification documentation was missing. HHA staff will review all 17 newly leased units from the Audit period to assure compliance. In addition, HHA has implemented a system for all new lease ups to assure full compliance with Rent Reasonableness documentation. This includes the Assistant Director of Management reviewing all files before a unit is leased. Marc A. Recko, Executive Director was designated to be responsible for implementing this corrective action by September 30, 2026.
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. To that end, ...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers program to ensure that established internal control policies are being followed on a timely basis. To that end, in October of 2025, the month after the current Audit period, HHA brought on an outside firm (Nan McKay and Associates) to assure the completeness and correctness of all new admissions and recertification and regulatory file requirements. Our new system includes a quality control review after Nan McKay provides HHA with a completed new admission or recertification file. Marc A. Recko, Executive Director was designated to be responsible for implementing this corrective action by September 30, 2026.
Finding 2025-002: Allowable Costs – Payroll Assistance Listing #: 93.671 Recommendation: Deleon & Stang recommends MSP make changes overall its timekeeping processes to ensure that payroll costs accurately reflect work performed and if budget estimates are utilized, that they are reconciled and true...
Finding 2025-002: Allowable Costs – Payroll Assistance Listing #: 93.671 Recommendation: Deleon & Stang recommends MSP make changes overall its timekeeping processes to ensure that payroll costs accurately reflect work performed and if budget estimates are utilized, that they are reconciled and trued up on a consistent basis. Management Response: MSP agrees with the recommendation and remains committed to improving its timekeeping and payroll allocation processes. Management is working with ADP to implement a system that captures actual employee time by program and grant, ensuring payroll costs are accurately charged and supported by documented effort. Until full implementation is complete, periodic reconciliations between budgeted and actual time will be performed. Action Plan: 1. Complete ADP system enhancements that allow employees to record time by department,program, and grant. 2. Establish written procedures requiring staff to allocate hours based on actual workperformed. 3. Implement monthly reviews and reconciliations of payroll allocations against actual timerecords. 4. Train supervisors and employees on the revised timekeeping process. 5. Perform quarterly management reviews of payroll distributions and make necessaryadjustments to ensure compliance with Uniform Guidance requirements. 6. Target full implementation and testing of the enhanced timekeeping system prior to thenext audit cycle.
Finding 2025-001: Procurement, Suspension, and Debarment Assistance Listing #: 14.267 Recommendation: Delong & Stang recommend MSP perform its internal processes and retain documentation of the suspension and debarment check in the vendor file as support for vendors who are paid or expected to be pa...
Finding 2025-001: Procurement, Suspension, and Debarment Assistance Listing #: 14.267 Recommendation: Delong & Stang recommend MSP perform its internal processes and retain documentation of the suspension and debarment check in the vendor file as support for vendors who are paid or expected to be paid over $25,000 prior to funds being disbursed. Management Response: MSP agrees with the recommendation and will strengthen its vendor verification process by ensuring that all vendors expected to receive payments of $25,000 or more are screened through SAM and OIG prior to contract execution or payment. Documentation supporting these verifications will be retained in the vendor file and reviewed periodically for compliance. Action Plan: 1. Update the procurement checklist to include mandatory SAM and OIG verification before payment approval. 2. Create a standardized electronic filing system for verification documentation. 3. Train finance and program staff on suspension and debarment requirements. 4. Conduct quarterly reviews of vendors exceeding the $25,000 threshold to ensure compliance and documentation retention. 5. Assign responsibility to the Finance Manager for monitoring and maintaining compliance records.
Management Response and Corrective Action Plan Finding 2025-001 – Allowability Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: 93.859 Responsible Individual: BIDMC – Jarod Kohr, Director, Research Finance o...
Management Response and Corrective Action Plan Finding 2025-001 – Allowability Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: 93.859 Responsible Individual: BIDMC – Jarod Kohr, Director, Research Finance or The Center - Roy Bourne, Director, Research Finance and Operations Contact Information: BIDMC - jkohr@bidmc.harvard.edu; 617-216-7479 The Center - rbourne2@joslin.harvard.edu; 617-309-5741 A review of Beth Israel Deaconess Medical Center’s (BIDMC) salary allocation process revealed 53 instances out of approximately 11,000 records of allocation in excess of NIH Salary Cap limits (0.04%). BIDMC acknowledges discovery of system limitations that will correct future instances. Accordingly, management has concluded that controls are operating as intended, but will be enhanced to limit human errors. Corrective Action Plan: - Management will implement a calculation control that will prevent the ability to save changes to salary allocation that exceeds the salary cap for the respective period. (Completed) - Management will implement a calculation control that will prevent the ability to reflect a percent salary higher than the percent effort for any salary cap controlled grant. (Completed) - Management will monitor monthly changes to effort/salary allocations in the Time and Effort system for calculated variances. (Ongoing) Expected Completion Date: October 1, 2026 Status of Completion: In process The Center’s management acknowledges that an invoice was incorrectly matched to a purchase order; however, this was not reflective of the overall control environment. The Center maintains established controls over purchase order invoice processing, including system-generated duplicate invoice detection, cost matching tolerances, and restrictions preventing matching to closed purchase orders. Transactions outside established parameters are automatically flagged for manual review. Management performed a targeted review of these transactions, noting expenditures were properly allocated with the exception of the item noted in this finding. Accordingly, management has concluded that controls are operating effectively overall, Accordingly, management has concluded that controls are operating effectively overall, while continuing to evaluate and enhance processes to further mitigate the risk of recurrence. Corrective Action Plan: - Management will reinforce matching requirements through targeted training and communication with Accounts Payable and Purchasing (Completed) - Periodic reconciliation reviews will be performed to identify and correct any misallocated costs as necessary (Completed) - The Center’s planned implementation of a new ERP system on October 1, 2026 will introduce enhanced automated matching controls, further reducing the likelihood of recurrence Expected Completion Date: October 1, 2026 Status of Completion: In process
Management acknowledges the importance of cash management policies with regards to reimbursable programs. Day Kimball Healthcare is committed to full compliance with federal cash management requirements and takes seriously its obligation to request reimbursement only after program expenditures have ...
Management acknowledges the importance of cash management policies with regards to reimbursable programs. Day Kimball Healthcare is committed to full compliance with federal cash management requirements and takes seriously its obligation to request reimbursement only after program expenditures have been both incurred and paid. During fiscal year 2025, the employee responsible for previous reporting of these expenses retired, and the job function of submission and review of this grant passed on to other individuals. Management recognizes that our existing review process did not include a sufficient control step to verify payment status prior to submission of reimbursement requests, and employees have now been trained on proper procedure, which includes confirmation of payment of expenses before submission is allowed. In addition, the reviewer is now aware of this requirement and confirmation of payment is now a part of this individual’s responsibilities as well. Going forward into fiscal year 2026 Management believes these controls will prevent similar findings from occurring. Sheena Farner, Director of Budget & Financial Reporting, will oversee this corrective action plan to be fully implemented by September 30, 2026.
Written Policies Required by the Unfiform Grant Guidance Auditor Description of Criteria, Condition, and Effect: The Uniform Guidance requires a non-federal entity that has expended federal awards for a grant awarded on or after December 26, 2014 to have written policies pertaining to: 1) Payments (...
Written Policies Required by the Unfiform Grant Guidance Auditor Description of Criteria, Condition, and Effect: The Uniform Guidance requires a non-federal entity that has expended federal awards for a grant awarded on or after December 26, 2014 to have written policies pertaining to: 1) Payments (draws of federal funds and how to minimize the time lapsing between the receipt of federal funds and the disbursement to contractors/employees/subrecipients) (§200.302(6)); 2) Allowability of costs charged to federal programs (§200.302(7)); and 3) Compensation (personnel and benefits policy) (§200.430 and §200.431). Although the County has processes in place to cover these areas, there are no formal written policies covering payments, allowability of costs, and compensation. As a result of this condition, the County did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation: We are aware that the County is evaluating options using internal and external resources to take corrective action. We recommend that the County proceed with its selected option as soon as practical, but no later than the end of the next fiscal year. Corrective Action: The County will proceed with its selected option no later than the end of the next fiscal year. Responsible Person: Susan Maier, Director of Fiscal Services Anticipated Completion Date: December 31, 2026
2025-001 ALN 14.871 – Housing Choice Voucher Program – Eligibility The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Responses. Person Responsible for Correction of Finding: Franklin Scott Jr., Executive Director P...
2025-001 ALN 14.871 – Housing Choice Voucher Program – Eligibility The Executive Director acknowledges the finding and is following the auditor's recommendation as listed in the Schedule of Findings and Responses. Person Responsible for Correction of Finding: Franklin Scott Jr., Executive Director Projected Completion Date: September 30, 2026
Finding 2025-005 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and complianc...
Finding 2025-005 Plan: Please see below the new process regarding hiring additional staff and turnover at Community Action Program Belknap-Merrimack Counties Inc. Due to lack of management, it is understood the importance of having staff training on a regular basis to ensure management and compliance duties can be performed adequately. Community Action Program Belknap-Merrimack Counties Inc. plans to improve the standards of employee training and will be hosting quarterly trainings on employee responsibilities, performance, and areas for improvement. This includes HUD trainings and keeping up to date on any new HUD policies and procedures. We understand the importance of a well-trained staff. We are committed to our performance and adhering to HUD standards while implementing policies to follow for continuous improvement. Please see below the new process regarding filling vacancies and completing management duties in a timely manner: 1. Immediate Focus on Vacancies: We are prioritizing the filling of vacant units by having two staff members complete move ins at the same time. 2. Streamlined Recertification Process: We have updated our process to ensure all tenants are recertified in a timely manner. There has been a new system in place to monitor deadlines and improve efficiency. 3. Staffing and Training: We are actively recruiting and training additional staff to ensure these tasks are handled promptly, preventing future delays. These steps will address the backlog of management duties and ensure that all tasks, such as filling vacancies and completing tenant recertifications, are handled in a timely and efficient manner. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Anticipated Completion Date: 12/31/2025 Contact: Jackie Oliveira, Director of Affordable Housing
Finding 2025-004 Plan: Management acknowledges this finding. The surplus cash deposit was not made within the required 90-day timeframe following fiscal year-end because an Owner-Certified REAC submission was filed while awaiting completion of the audited financial statements. Management incorrectly...
Finding 2025-004 Plan: Management acknowledges this finding. The surplus cash deposit was not made within the required 90-day timeframe following fiscal year-end because an Owner-Certified REAC submission was filed while awaiting completion of the audited financial statements. Management incorrectly believed the surplus cash calculation and deposit could be deferred until the audited REAC was submitted. To prevent this from occurring in the future, management has implemented a procedure requiring surplus cash to be calculated immediately following fiscal year-end, regardless of whether an Owner-Certified REAC or Audited REAC is submitted. Management will estimate and deposit any required surplus cash into the Residual Receipts Account within HUD's required 90-day timeframe and make any necessary adjustments after the audited financial statements are completed. Management has reviewed HUD requirements with applicable staff and will monitor future year-end submissions to ensure compliance with all surplus cash deposit requirements. Contact: Jackie Oliveira-Director of Affordable Housing Completion Date: 03/31/2026
Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen agai...
Finding 2025-002 Plan: The Human Resource Director will work with Paylocity to find out why the mapping on the file they provide was incorrect. The Human Resource Director will have Paylocity (our third party payroll provider) make the necessary corrections on their end, so this will not happen again. Anticipated Completion Date: 12/31/2025 Contact: Jill Lesmerises, CFO
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service ...
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service coverage ratio for the year ended December 31, 2025. Additionally, the Hospital does not have a control process in place to ensure that the monitored debt service coverage ratio is accurate and non-compliance is reported timely. Responsible Individuals: Eric J. Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to monitor compliance with debt covenants, including the periodic calculation of debt service coverage ratio, documentation of management review and approval, and timely communication with the lender if noncompliance is identified. Anticipated Completion Date: September 30, 2026
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization...
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization, building on its established procurement policies, implemented stricter headquarters oversight and approval requirements for higher-risk and higher-dollar procurements, including defined approval thresholds for procurement solicitations, evaluation activities, and contract execution. Specialized and international procurements now require additional senior-level review and involvement, regardless of value. 2. Strengthened Vendor Due Diligence and Market Research Procedures The Organization updated procurement procedures to require expanded documentation of vendor due diligence and market research activities, including enhanced validation of vendor qualifications, procurement support documentation, and vendor representations associated with federal procurements. 3. Enhanced Monitoring of Procurement Documentation and Compliance Requirements Management implemented strengthened review procedures over procurement advertisements, vendor certifications, geographic code compliance documentation, and other supporting procurement records. The revised procedures also require additional review and escalation for identified procurement irregularities or inconsistencies. 4. Advance Payment and Approval Controls The Organization implemented revised controls governing advance payments, including enhanced approval requirements for significant prepayments and additional supporting documentation requirements for high-risk payment arrangements. 5. Procurement Evaluation and Technical Assistance The Organization enhanced procurement evaluation oversight by requiring additional Headquarters participation in evaluation activities for procurements exceeding defined thresholds. In addition, the Organization engaged specialized procurement and logistics resources to provide technical assistance and support for international procurement activities. 6. Personnel Actions and Training The Organization took personnel actions in response to the investigation findings and implemented enhanced procurement and compliance training for relevant personnel involved in procurement and grants management activities. Management believes these corrective actions appropriately address the control deficiencies identified in the finding and strengthen the Organization’s internal control over compliance related to procurement activities under federally funded programs. Anticipated Completion Date: Substantially completed as of April 6, 2026, with ongoing monitoring and training activities continuing through fiscal year 2026.
Management agrees with the finding. Policies and procedures as described above will be established and implemented during the current year.
Management agrees with the finding. Policies and procedures as described above will be established and implemented during the current year.
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inv...
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inventory review into its quarterly internal oversight process to ensure compliance with this requirement on an ongoing basis. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director
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