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Corrective Action Plans

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Finding 558995 (2024-002)
Significant Deficiency 2024
Almost Home, Inc.
CO
Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
After FY2024, Almost Home ceased using Temporary Assistance for Needy Families (TANF) to cover the cost of Severe Weather Activation Vouchers (SWAP) for TANF-eligible families. From this point forward, TANF will only be used for clients meeting all TANF eligibility requirements.
After FY2024, Almost Home ceased using Temporary Assistance for Needy Families (TANF) to cover the cost of Severe Weather Activation Vouchers (SWAP) for TANF-eligible families. From this point forward, TANF will only be used for clients meeting all TANF eligibility requirements.
View Audit 355240
Finding 558991 (2024-001)
Significant Deficiency 2024
Almost Home, Inc.
CO
Reporting § 200.510
Almost Home has begun establishing and finalizing a formal SEFA preparation schedule. Almost Home will also be retaining a CPA/Audit Consultant to work with the staff and conduct periodic reviews of the audit process and status.
Almost Home has begun establishing and finalizing a formal SEFA preparation schedule. Almost Home will also be retaining a CPA/Audit Consultant to work with the staff and conduct periodic reviews of the audit process and status.
View Audit 355240
Finding 558986 (2024-006)
Material Weakness 2024
Dakota Rural Water District
ND
Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326
Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written p...
Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Jordyne Lee, General Manager Corrective Action Plan: The District will review the applicable 2 CFR 200 sections and implement procedures necessary to ensure compliance with all of these requirements. Anticipated Completion Date: December 31, 2025.
View Audit 355234
Finding 558985 (2024-006)
Material Weakness 2024
Shelter and Assistance in Family Emergencies, Inc.
MS
Questioned Costs Internal Control / Segregation of Duties Cash Management
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...
Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.
View Audit 355230 Questioned Costs: $1
Grandview Apartments, Inc.
PA
Questioned Costs HUD Housing Programs Reporting
Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 o...
Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 on 3/25/2025. The finding is cleared.
View Audit 355222 Questioned Costs: $1
Grandview Apartments, Inc.
PA
Questioned Costs HUD Housing Programs Reporting
Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management submitted a Form 9250 Fund Authorization on March 26, 2025 for combined 2024 unapproved withdrawals and additional 2025 fund requests. Management is awaiting approval.
Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management submitted a Form 9250 Fund Authorization on March 26, 2025 for combined 2024 unapproved withdrawals and additional 2025 fund requests. Management is awaiting approval.
View Audit 355222 Questioned Costs: $1
Calvin Court, Atlanta, Inc.
GA
Cash Management HUD Housing Programs Internal Control / Segregation of Duties
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes tha...
Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.
View Audit 355218
Calvin Court, Atlanta, Inc.
GA
Internal Control / Segregation of Duties
Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are...
Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.
View Audit 355218
Finding 558976 (2024-001)
Significant Deficiency 2024
Community Health Center Dba Alluvion Health, Inc.
MT
Internal Control / Segregation of Duties Special Tests & Provisions Significant Deficiency
Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...
Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.
View Audit 355210
Finding 558975 (2024-001)
Material Weakness 2024
City of Diamond Bar
CA
Subrecipient Monitoring Material Weakness Reporting
Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the...
Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the integrity and effectiveness of the program. Training and Awareness: The City will provide comprehensive training to all relevant staff/consultants on the continuing loan monitoring requirements outlined in the LACDA grant agreement and CDBG program guidelines. Training sessions will be completed by June 30, 2026. Policy and Procedure Updates: The City will review and update its internal policies and procedures to clearly document the continuing loan monitoring process. A standardized compliance checklist and loan monitoring schedule will be developed to ensure consistent implementation across all loans. Loan Monitoring and Documentation: By June 30, 2026 the City will implement a regular schedule for evaluating outstanding loans, including, borrower compliance reviews, and follow-up actions where necessary. All monitoring activities will be fully documented and retained in each loan file. Ongoing Oversight: Management will assign a designated staff member/consultant responsible for overseeing the continuing loan compliance process, ensuring ongoing adherence to program requirements and addressing any issues promptly. The City is committed to strengthening internal controls, ensuring compliance with grant requirements, and maintaining the credibility of the Home Improvement Program. Proposed Completion Date: The corrective actions outlined above will be fully implemented by June 30, 2026.
View Audit 355203
Finding 558971 (2024-006)
Significant Deficiency 2024
Polytechnic University of Puerto Rico, Inc.
PR
Student Financial Aid Special Tests & Provisions Eligibility
All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...
All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.
View Audit 355176
Finding 558969 (2024-005)
Material Weakness 2024
Polytechnic University of Puerto Rico, Inc.
PR
Questioned Costs Procurement, Suspension & Debarment § 200.319 § 200.320
Revise and standardize the Sole Provider Justification form to require all federally mandated elements under 2 CFR 200.320. Train all staff involved in procurement activities on the updated requirements and documentation standards. Implement a review and approval step within the new ERP system to ve...
Revise and standardize the Sole Provider Justification form to require all federally mandated elements under 2 CFR 200.320. Train all staff involved in procurement activities on the updated requirements and documentation standards. Implement a review and approval step within the new ERP system to verify that all sole-source procurements meet the full documentation standards before processing. Conduct periodic internal audits of procurement files to ensure continued compliance. Require management approval for any noncompetitive procurement exceeding micro-purchase thresholds.
View Audit 355176 Questioned Costs: $1
Finding 558965 (2024-004)
Significant Deficiency 2024
Polytechnic University of Puerto Rico, Inc.
PR
Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Monitor compliance through regular internal reviews and sample audits of personnel records.
Monitor compliance through regular internal reviews and sample audits of personnel records.
View Audit 355176
Finding 558956 (2024-003)
Significant Deficiency 2024
Polytechnic University of Puerto Rico, Inc.
PR
Cash Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. C...
Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. Conduct training to clarify and reinforce individual roles and responsibilities. Introduce periodic internal reviews to verify compliance with segregation protocols.
View Audit 355176
Finding 558949 (2024-002)
Significant Deficiency 2024
Polytechnic University of Puerto Rico, Inc.
PR
Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.305
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the G...
Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it’s under implementation and will address this issue as part of the implementation process.
View Audit 355176
Finding 558946 (2024-001)
Significant Deficiency 2024
Polytechnic University of Puerto Rico, Inc.
PR
Allowable Costs / Cost Principles Student Financial Aid Cash Management
Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.
Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.
View Audit 355176
Finding 558941 (2024-002)
Significant Deficiency 2024
Fisk University
TN
Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512
Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financ...
Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financial reporting and audit preparation processes. Items that can be compiled prior to year-end will be identified and the compilation of those items will begin. Areas that presented challenges during the FY 24 audit will be given special attention in advance. Lastly, audit assignments will be delegated to improve response efficiency. A detailed closing schedule has been developed. Staff duties and responsibilities have been reassigned and repurposed to improve processing timelines and audit preparation. The audit timeline will be monitored more closely to ensure timely responses to audit requests that support the timely completion and issuance of the audit to meet Uniform Guidance timeline requirements.
View Audit 355168
Finding 558936 (2024-001)
Significant Deficiency 2024
Fisk University
TN
Student Financial Aid Cash Management Matching / Level of Effort / Earmarking
Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdow...
Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdown. The Student Financial Aid Office (SFA) will authorize Title IV awards and notify the Bursar and the Grants Account. The Bursar will facilitate disbursement of the funds to the students’ accounts and notify the Grants Accountant once the disbursement has been processed. The Grants accountant will facilitate the drawdown of funds after the funds have been disbursed. This will mitigate the potential recurrence of funds being drawn down prior to being disbursed to students’ accounts resulting in the potential for noncompliance with the three-day window.
View Audit 355168
Finding 558935 (2024-010)
Material Weakness 2024
Lafayette City_parish Consolidated Government
LA
Procurement, Suspension & Debarment
U.S. DEPARTMENT OF TREASURY: Coronavirus Capital Projects Fund (21.029) 2024-010 Controls over Suspension and Debarment Recommendation: The Government should review their established controls, policies and procedures to ensure that the verification of vendors is done prior to doing business with ...
U.S. DEPARTMENT OF TREASURY: Coronavirus Capital Projects Fund (21.029) 2024-010 Controls over Suspension and Debarment Recommendation: The Government should review their established controls, policies and procedures to ensure that the verification of vendors is done prior to doing business with them. Corrective Action Plan: The Government agrees with this finding. Purchasing is normally alerted to verify suspension and debarment status when PO’s are issued in designated federal grant funds. However, we have a few departments that do not report grants in separate funds. If these departments do not identify that a federal grant is the funding source when initiating the procurement process, then Purchasing is not aware that the verifications need to be made. We will review the documentation requirements with the appropriate departments so that purchases made with grant funds in these departments are properly identified. We do not expect this finding to reoccur.
View Audit 355166
Finding 558934 (2024-011)
Material Weakness 2024
Lafayette City_parish Consolidated Government
LA
Allowable Costs / Cost Principles
U.S. DEPARTMENT OF TREASURY: Coronavirus State and Local Fiscal Recovery Funds (21.027) 2024-011 Compliance with Allowable Costs Recommendation: The Government should review their established controls, policies and procedures for ef...
U.S. DEPARTMENT OF TREASURY: Coronavirus State and Local Fiscal Recovery Funds (21.027) 2024-011 Compliance with Allowable Costs Recommendation: The Government should review their established controls, policies and procedures for effectiveness and ensure invoices submitted by the vendor include detailed support for all expenses incurred. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: The Government agrees with this finding. While the actual cost itself is allowable, we acknowledge that the supporting documentation for the transaction was not present at the time of payment. We have discussed the invoice and documentation issues with the vendor, who will modify the invoices to comply in future billing periods. We have also discussed the lack of documentation and corrective action with staff in charge of reviewing and approving these invoices for payment. We do not expect this finding to reoccur.
View Audit 355166
Lafayette City_parish Consolidated Government
LA
Questioned Costs Allowable Costs / Cost Principles
Coronavirus State and Local Fiscal Recovery Funds (21.027) 2024-009 Compliance with Allowable Costs Recommendation: The Government should review their established controls, policies and procedures for effectiveness and ensure invoices submitted by the vendor include detailed support for all expens...
Coronavirus State and Local Fiscal Recovery Funds (21.027) 2024-009 Compliance with Allowable Costs Recommendation: The Government should review their established controls, policies and procedures for effectiveness and ensure invoices submitted by the vendor include detailed support for all expenses incurred. Additionally, management should ensure all costs charged to the program are allowable under the grant guidelines. Corrective Action Plan: The Government agrees with this finding. While the actual cost itself is allowable, we acknowledge that the supporting documentation for the transaction was not present at the time of payment. We have discussed the invoice and documentation issues with the vendor, who will modify the invoices to comply in future billing periods. We have also discussed the lack of documentation and corrective action with staff in charge of reviewing and approving these invoices for payment. We do not expect this finding to reoccur.
View Audit 355166 Questioned Costs: $1
Finding 558862 (2024-065)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will...
Finding: The Community Colleges of Spokane did not have adequate controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: The College District will enhance our monthly financial reporting to include a unique identifier for monthly expenditures. Additionally, a report of expenditures procured by credit card will be attached to the regular financial report. The College District acknowledges the importance of clear documentation and tracking of the required training and meeting attendance by all Board of Trustees members and Policy Council members. Beginning in March 2025, the College District started providing additional methods and opportunities for new members to receive fiscal and governance training. To strengthen controls over program governance requirements and to demonstrate the commitment to continuous improvement of existing processes, the College District will further document training completion and the distribution of monthly financial information to all members. Completion Date: Estimated June 2025 Agency Contact: Linda McDermott Chief Financial Officer 501 N Riverpoint Blvd, PO Box 6000 Spokane, WA 99217-6000 (509) 434-5275 Linda.McDermott@ccs.spokane.edu
View Audit 355165
Finding 558861 (2024-064)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has rev...
Finding: Skagit Valley College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: The College has reviewed and strengthened current internal controls to ensure the Board receives the required financial and credit card statements monthly and that all new Board members receive training within the required 180 days. Financial reporting procedures The Head Start Program Director prepares monthly reporting to be available for inclusion in the monthly board packet, or as requested. In January 2025, the Procedures of Policy Council and Board Reporting were updated to ensure that required monthly reporting is provided to each governing body, regardless of whether there is a scheduled meeting for that month. This procedure became effective for the February 2025 Board of Trustees meeting. All financial reporting that was not previously provided to the Board of Trustees for the period covering July 1, 2023, through December 31, 2024, was transmitted on February 24, 2025. Board member training In January 2025, the Head Start Director provided the Board of Trustees an updated document on the program’s selection criteria and enrollment process. Additionally, the Head Start Board of Trustees Handbook, which has incorporated other training materials, was provided to each board member. The Head Start Director will conduct an annual review of the handbook content and update as appropriate to ensure training materials remain current. Completion Date: March 2025 Agency Contact: Mike Cogan VP of Administrative Services and CFO 2405 East College Way Mount Vernon, WA 98273-5899 (360) 899-2945 mike.cogan@skagit.edu
View Audit 355165
Finding 558860 (2024-063)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with program governance requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Status: Corrective action in progress Corrective Action: In response to the audit finding, the College will explore options for a Governing Body that complies with governance requirements for the Head Start program. By May 2025, the College will consult with its Assistant Attorney General to discuss the composition of a new Governing Body and will take the necessary steps to fully comply with federal regulations. By July 2025, the College will: • Establish a Governing Body that is compliant with requirements outlined in the Head Start Act to perform the required monthly review of financial and credit card statements, major financial expenditures, and any funding applications. • Ensure the Policy Council receives and approves the required financial and credit card statements each month. • Provide training to the new Governing Body and active members of the Policy Council within the required 180 days. Completion Date: Estimated July 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
View Audit 355165
Finding 558859 (2024-062)
Material Weakness 2024
State of Washington C/o Office of Financial Management
WA
Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response ...
Finding: Edmonds College did not have adequate internal controls over and did not comply with protection of federal interest requirements for its Head Start program. Questioned Costs: Assistance Listing # 93.600 Amount $0 Status: Corrective action complete Corrective Action: In response to the audit finding, Edmonds College has completed the following: • Established a written protocol with the Department of Enterprise Services (DES) to ensure the Head Start Program Performance Standards 1303.46 is met in recording and posting federal interest. • Established internal controls to ensure college management monitor future work with DES to properly complete the Office of Head Start Lease Rider attachment in the lease agreements where federal funds are used to renovate leased property. Completion Date: February 2025 Agency Contact: Ginger Williams Head Start Executive Director 20816 44th Ave. W. Lynnwood, WA 98036-7744 (425) 550-3840 ginger.williams@edmonds.edu
View Audit 355165
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