Corrective Action Plans

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Finding: 2024-003 Internal Controls over Preparation of SEFA. Finding Type: Material weakness. Name of Contact Person: Matt Stines, Superintendent. Recommendation: We recommend that the District strengthen its policies and procedures to ensure that all federal expenditures can be prepared in an accu...
Finding: 2024-003 Internal Controls over Preparation of SEFA. Finding Type: Material weakness. Name of Contact Person: Matt Stines, Superintendent. Recommendation: We recommend that the District strengthen its policies and procedures to ensure that all federal expenditures can be prepared in an accurate, comprehensive list for each fiscal year within 90 days of the fiscal year end. Corrective Action: The District is in agreement and will strengthen its policies and procedures to ensure that all federal expenditures are reported and prepared in an accurate, comprehensive list of federal revenues and expenditures for each fiscal year within. Proposed Completion Date: June 1, 2025.
We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN) per the grant agreements in the initial review of the SEFA. The improved procedures will provid...
We have reviewed the control procedures around preparation and review of the schedule of expenditures of federal awards (SEFA) and implemented an independent review of the assistance listing numbers (ALN) per the grant agreements in the initial review of the SEFA. The improved procedures will provide the needed structure to fulfill management's responsibility to accurately report the grantor agency / pass-through grantor, assistance listing number, federal program name and number, and expenditures. Identification of major programs, utilizing the guidelines in the Office of Management and Budget's (OMB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) are the responsibility of the auditor.
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors we...
Institutional Comments on Findings and Recommendations: The institution is fully aware of the Enrollment Reporting requirements and deadlines. The institution agrees with the auditor that there were two (2) cases where the enrollment status was reported late and three (3) cases where the auditors were unable to verify that changes in student status were reported. The institution informed the auditors that its current policy and procedure is to report all changes to student status monthly instead of every two months as established by the NSLDS reporting schedule to avoid cases on non or late reporting. Since the institution does not maintain copies of the report of enrollment changes that it submits to NSLDS and since the current NSLDS database does not maintain students that are inactive, it was unable to evidence the changes or updates that were made for these students to the auditors. Actions Taken or Planned: The institution has already discussed this issue as observed by the auditors with the officer in charge ofNDSLS Enrollment reporting. The institution would continue with its policy to submit Enrollment Reports monthly to update and notify changes to student's enrollment status more effectively and to avoid cases of late or non-compliance. Status of Corrective Actions on Prior Findings: Some of the issues related to this finding occurred in the past audit.
Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files ...
Finding: 2024-001 Program Name: Section 8 Project-Based Cluster (14.195/14.249) Federal Awarding Agency: Department of Housing and Urban Development Compliance Requirement: Housing Quality Standards Type of Finding: Significant Deficiency; Nonmaterial Noncompliance Condition: Of the 40 tenant files tested, 7 files did not contain documentation that the annual inspection was performed. Auditor Recommendation: We recommend the Agency uilize a tracking system to ensure inspections are completed annually and documentation is maintained regarding the results of the annual inspections. Management’s Response: The Property Management department will coordinate with the Information Technology team to ensure appropriate documentation and tracking of annual inspections.
Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future o...
Upon review of the one case file, it appears that the lapse occurred during a turnover in staff assignment. Both the original attorney assigned to this case and the subsequent attorney left the firm and as a result there was a failure to disclose it to LSC. To address this issue and prevent future occurrences, we are implementing the following corrective actions within the next 60 days:  Case Transfer Protocol: We are creating a case transfer memo form for Legal Server. We will include an assessment of whether the case needs to be reported during the next LSC Case Disclosure Report.  Case Management System Updates: We are also working on a litigation module for Legal Server that will allow us to track when a case moves from pre-litigation to litigation so that we can easily identify cases that should be included in LSC Case Disclosure Report.  Staff Training: Ongoing training is being provided to ensure all attorneys and advocates understand the importance of timely and accurate disclosures, especially during case transfers.
This finding is related to activities on our VOCA grants. This exception was related to a process in place prior to May 2023 for allocating our outside contracted IT services Again, in May 2023 FRLS added an electronic transaction approval process via Teams, that documents approvals for all our AP, ...
This finding is related to activities on our VOCA grants. This exception was related to a process in place prior to May 2023 for allocating our outside contracted IT services Again, in May 2023 FRLS added an electronic transaction approval process via Teams, that documents approvals for all our AP, AR and other transactions initiated by our accounting staff. These are reviewed and approved by the CFO before being posted into the GL. FRLS failed to update its allocation for this prior allocation method for this legacy vendor. The CFO will undertake a review of this process to ensure that we are in compliance with allowable cost documentation requirements. We will also review and update our documentation of allocations and ensure that each month’s allocation is properly approved. This change will be made within the next 60 days.
View Audit 354985 Questioned Costs: $1
FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our...
FRLS is in the process of having its PAI program reviewed through the ABA peer review process to assess options for meeting LSC’s PAI requirements. With respect to the waiver carryover, the CFO had conversations with LSC representatives on the proper computation of this and for 2024 LSC approved our carryover computation. Upon further consultation with LSC It appears that this information was incorrect and FRLS will revise its computation in consultation with LSC. This change will be made by December 31, 2025.
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and ...
This finding is related to activities on our VOCA grants. This finding is related to Finding 2024-001. 4 invoices were not approved by management. FRLS’s AP policy that was adopted in September 2024 allowed us to skip separate management approval in cases of recurring invoices such as utilities and in cases where we have approved contracts such as rent payments, software subscriptions etc. This was our policy before September 2024, but it was not formalized before that date. As in the case of 2024-001. FRLS will modify its AP Policy and Procedures to remove this recurring payment exception and will now require all invoices be approved by management by routing invoices to management for approvals through the Teams automated system. Invoices over $5,000 will also be required to be approved by the Executive Director or their temporary designee. Such designation must be made in writing. This change will be made within the next 60 days.
This finding relates to activities on our Legal Services Field Grant. As part of FRLS’ post 2023 audit review, we implemented an update to our payroll accounting system that streamlined the process for uploading and properly coding employee time, salaries and benefits to the proper grant codes based...
This finding relates to activities on our Legal Services Field Grant. As part of FRLS’ post 2023 audit review, we implemented an update to our payroll accounting system that streamlined the process for uploading and properly coding employee time, salaries and benefits to the proper grant codes based upon a biweekly time reporting system. The exception created here came from a one-time payout for paid time off and as a result was not properly recorded to the correct grant codes. FRLS will be implementing within the next 60 days an update to its cost allocation policies to ensure any future “nonstandard” payroll payments are properly allocated.
View Audit 354985 Questioned Costs: $1
Finding 2024-002: Comments on the Finding and Each Recommendation During prior years, the Board of Directors disbursed funds from the replacement reserve to fund development of other housing developments. Effective June 10, 2022, the Board of Directors entered into a repayment agreement with HUD t...
Finding 2024-002: Comments on the Finding and Each Recommendation During prior years, the Board of Directors disbursed funds from the replacement reserve to fund development of other housing developments. Effective June 10, 2022, the Board of Directors entered into a repayment agreement with HUD to return funds to the Corporation. The agreement required $3,000 and $6,950, respectively, to be returned to the Corporation during the years ended December 31, 2024 and 2023. The Board of Directors returned $250 and $1,400, respectively, during the years ended December 31, 2024 and 2023. At December 31, 2024 and 2023, the Board of Directors owes $53,350 and $54,750, respectively, to the Corporation. Action(s) taken or planned on the finding The Board of Directors should replace the funds that were disbursed from the reserve for replacements without HUD approval in accordance with the repayment agreement entered into with HUD on June 10, 2022. Management and the Board of Directors concur with the finding and the auditor's recommendation. The Board of Directors is working on making the delinquent deposits for 2023 and 2024 and all future deposits as required in the repayment agreement entered into with HUD on June 10, 2022.
Finding 2024-001: Comments on the Finding and Each Recommendation The Corporation has not filed the 2017, 2018, 2019, 2020, 2021, 2022, or 2023 federal income tax returns. Action(s) taken or planned on the finding Tax returns should be filed on a timely basis and all delinquent tax returns shou...
Finding 2024-001: Comments on the Finding and Each Recommendation The Corporation has not filed the 2017, 2018, 2019, 2020, 2021, 2022, or 2023 federal income tax returns. Action(s) taken or planned on the finding Tax returns should be filed on a timely basis and all delinquent tax returns should be filed as soon as possible. Management and the Board of Directors concur with the finding and the auditor's recommendation. Management and the Board of Directors are taking steps to file the previous tax returns and have the Corporation's not-for-profit designation reinstated.
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowab...
Finding 2024-005: U.S. Department of Housing and Urban Development – CFDA #14.155 Mortgage Insurance for the Purchase or Refinance of Existing Multifamily Housing Projects Applicable Federal Award Number and Year – HUD loan under section 207/223(f), HUD Project No. 101-11316 Allowable Costs/ Allowable Activities Name of contact Person: Renee Gallegos, Finance Manager Anticipated completion date: Completed Planned Corrective Action: • Management has updated internal controls to include that all costs charged to the project are for allowable costs.
View Audit 354976 Questioned Costs: $1
Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Correct...
Finding 2024-004: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 HQS Enforcement Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: In Progress Planned Corrective Action: • SMHO will provide additional staff training and testing of understanding through a thirdparty training platform for inspections and re-inspections procedures. Management will quarterly review each file that requires re-inspection to ensure all documents are present in the file.
Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...
Finding 2024-003: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for income used at new move-ins, port-ins and annual re-exams and the manager/lead will initial the new income line item added to the check sheet for each file to indicate the review/approval has been completed.
Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Ac...
Finding 2024-002: U.S. Department of Housing and Urban Development – CFDA #14.871 Housing Choice Vouchers Applicable Federal Award Number and Year- HCV2024 Eligibility Name of contact Person: Jenette Jemison, Director of Housing Operations Anticipated completion date: Completed Planned Corrective Action: • SMHO will require managerial file review/approval for all new move-ins, port-ins and annual re-exams and the manager/lead will sign the check sheet for each file to indicate the review/approval has been completed.
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2025
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures over payment requests to ensure allowability accuracy. Completion Date –December 31, 2025
View Audit 354950 Questioned Costs: $1
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Contact Person – Krista Martin, Director of Finance and Administration, and Ryan Riesinger, Executive Director Corrective Action Plan – Review and update procedures to ensure accurate reporting. Completion Date –December 31, 2025
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214...
Ensure full compliance with HUD regulations and internal policies related to eligibility documentation, income verification, utility allowances, and rent reasonableness determinations in the Housing Choice Voucher (HCV) program. 1. Correct the Deficiencies in the Identified Files Issue Missing 214 Declaration Form Utility Allowance Calculation (2 files) Missing Third-Party Income Verification Missing Rent Reasonableness Determination Action Contact tenant to obtain and file the signed 214 declaration. Recalculate and document the utility allowance using the current approved utility schedule. Request and obtain third-party verification; if unavailable, follow up with tenant and document efforts per HUD guidelines. Conduct and document rent reasonableness review for the current unit. Responsible Party Housing Specialist Housing Specialist Housing Specialist HQS/Rent Reasonableness Officer Timeline Within 10 business days Within 10 business days Within 10 business days Within 10 business days 2. Expand Review to Broader File Population Action Details Responsible Party Timeline Risk-based Review of Additional Files Identify Systemic Issues Report Findings Identify a representative sample of 100-200 files from the broader tenant population to assess the prevalence of the noted deficiencies. Track and categorize findings to identify patterns of noncompliance. Present findings to leadership and recommend procedural changes if systemic issues are found. Quality Assurance (QA) Team QA Manager QA Manager Within 45 days Within 60 days Within 75 days 3. Strengthen Policies, Procedures, and Staff Training Update Procedures Revise Standard Operating Procedures (SOPs) for file documentation, utility allowances, and rent reasonableness. Include clear checklists. Program Manager Within 90 days Staff Training Conduct mandatory refresher training on eligibility documentation,income verification protocols, rent reasonableness, and utility allowance schedules. File Audit Checklist Implement a standardized checklist for file reviews before final approval. 4. Ongoing Monitoring and Compliance Quarterly File Audits Continue random quarterly audits of tenant files to ensure ongoing compliance. Compliance Reporting Include compliance metrics in monthly management reports. Corrective Action Tracking Maintain a tracking system for noted deficiencies and corrective actions taken.
Finding 558082 (2024-001)
Significant Deficiency 2024
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the rep...
U.S. Department of Treasury No. 21.027 – Coronavirus State and Local Fiscal Recovery Funds Grant Period Year Ended December 31, 2024 Corrective Action Plan: In order to ensure future submissions are containing segregation of duties, the organization will ensure there are two people a part of the reporting and submission process. One person will fill out the reporting information and another person will sign off and submit the information to ensure two people are part of the process. Responsible for this plan: Ariel Rodriguez, Executive Director Implementation Timeline: Immediately as of April 22nd, 2025
2024-002- Inaccurate Schedule of Expenditures of Federal Awards (SEFA), Health Resources and Services Administration Native Hawaiian Health Care 93.932  Due to the significant increase in funding during the Lahaina wildfires, it was extremely difficult to recognize if funding were disbursed from a ...
2024-002- Inaccurate Schedule of Expenditures of Federal Awards (SEFA), Health Resources and Services Administration Native Hawaiian Health Care 93.932  Due to the significant increase in funding during the Lahaina wildfires, it was extremely difficult to recognize if funding were disbursed from a federal source. As of January 2025, the Executive Director inquires with the funding source if the award is a result of federal funds.
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefor...
2024-001-Internal Control over Financial, United States Department of Health and Human Services Administration, Native Hawaiian Health Care 93.932 Significant adjusting journal entries Due to the high turnover of fiscal staff in previous years, the Organization fell behind in our audits. Therefore, many adjusting entries were required to reconcile accounts, while upkeeping the current financial state of the Organization during fiscal year’s 2024 and 2025, accordingly. In addition to the high turnover, during fiscal year 2024, Maui experienced devastation with the Lahaina wildfires, which led to an increase of funding from donors to support the communities’ needs to recover. Again, our staff were challenged to meet the demands of the requirements of the funding and continue to monitor the previous fiscal year and the current fiscal years financial state. Internal control over disbursements We have made significant improvements from prior years in internal control processes, with regards to disbursements. With the turnover of staff, there was no communication of fiscal internal controls. Since the turnover, we have hired new staff and implemented processes and reviewed the internal controls policies with the new staff to address these issues. We expect these issues to be resolved in fiscal year ending 2025, as these findings have been carryover issues from previous years. Review of cancelled check images During fiscal year 2022, the bank statements no longer included copies of cancelled checks. Due to this change, the cancelled check images are available online. As of January 2025, the Executive Director reviews cancelled check images online monthly. She also reviews the bank statements for awareness of the transactions and balances of accounts monthly.
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the gr...
FINDING NUMBER: 2024-002 Condition: The CMHSP included all contract costs, including amounts over $25,000, in the modified total direct costs. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that amounts used to calculate indirect costs charged to the grant properly exclude contract amounts over the allowed limit. Planned Corrective Action: Going forward the Authority will calculate the indirect costs based on up to $25,000 per contract employee. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2025
View Audit 354928 Questioned Costs: $1
FINDING NUMBER: 2024-001 Condition: The CMHSP did not perform a review of sam.gov to ensure that the vendor was not suspended or debarred prior to entering into an agreement with them. A subsequent review of sam.gov was conducted showing that the vendor was not suspended or debarred. Recommendation...
FINDING NUMBER: 2024-001 Condition: The CMHSP did not perform a review of sam.gov to ensure that the vendor was not suspended or debarred prior to entering into an agreement with them. A subsequent review of sam.gov was conducted showing that the vendor was not suspended or debarred. Recommendation: We recommend that the CMHSP review/update policies and procedures to ensure that verification of suspension, debarment, and exclusion is conducted prior to entering a contract Planned Corrective Action: Going forward the Authority will follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2025
Finding 558068 (2024-002)
Significant Deficiency 2024
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: Management agrees with recommendation of refund operating cash for the distributions in excess of allowable surplus cash calculations and will refund operating cash. Responsible Party: Sherri Friedrich Estimated Completion: Cash will be refunded by May 31, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
View of Responsible Officials: The Project agrees and will replenish the replacement reserve account. Responsible Party: Sherri Friedrich Estimated Completion: Funds will be replenished by April 30, 2025
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