Corrective Action Plans

Finding 558103 (2024-006)

Significant Deficiency 2024

AL

Subrecipient Monitoring Significant Deficiency Special Tests & Provisions

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.

View Audit 354985

Finding 558102 (2024-005)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

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.

View Audit 354985

Finding 558101 (2024-004)

Significant Deficiency 2024

Florida Rural Legal Services, Inc.

AL

Questioned Costs Allowable Costs / Cost Principles

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 558098 (2024-002)

Significant Deficiency 2024

Dalewood Estates Senior Housing, Inc.

SC

Subrecipient Monitoring HUD Housing Programs Equipment & Real Property Management

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.

View Audit 354980

Finding 558097 (2024-001)

Significant Deficiency 2024

Dalewood Estates Senior Housing, Inc.

SC

Subrecipient Monitoring HUD Housing Programs

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.

View Audit 354980

Finding 558096 (2024-005)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

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 558095 (2024-004)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Eligibility HUD Housing Programs Significant Deficiency

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.

View Audit 354976

Finding 558094 (2024-003)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Internal Control / Segregation of Duties Eligibility HUD Housing Programs

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.

View Audit 354976

Finding 558093 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Littleton

CO

Internal Control / Segregation of Duties Eligibility HUD Housing Programs

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.

View Audit 354976

Finding 558090 (2024-004)

Significant Deficiency 2024

Grand Forks Regional Airport Authority

ND

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties

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

Finding 558089 (2024-003)

Significant Deficiency 2024

Grand Forks Regional Airport Authority

ND

Reporting Internal Control / Segregation of Duties Cash Management § 200.302 § 200.305

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

View Audit 354950

Finding 558086 (2024-001)

None 2024

Housing Authority of New Orleans

LA

Eligibility HUD Housing Programs Internal Control / Segregation of Duties

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.

View Audit 354949

Finding 558082 (2024-001)

Significant Deficiency 2024

Empower Evergreen INC

KS

Allowable Costs / Cost Principles Cash Management Period of Performance

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

View Audit 354940

Finding 558078 (2024-002)

Material Weakness 2024

Hui No Ke Ola Pono, Inc.

HI

Reporting

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.

View Audit 354936

Finding 558075 (2024-001)

Material Weakness 2024

Hui No Ke Ola Pono, Inc.

HI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring

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.

View Audit 354936

Finding 558070 (2024-002)

Significant Deficiency 2024

Sanilac County Community Mental Health Authority

MI

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring

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 558069 (2024-001)

Significant Deficiency 2024

Sanilac County Community Mental Health Authority

MI

Procurement, Suspension & Debarment § 200.214

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

View Audit 354928

Finding 558068 (2024-002)

Significant Deficiency 2024

Cornelia House

MN

Internal Control / Segregation of Duties

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 Audit 354917

Finding 558067 (2024-002)

None 2024

Carty Heights

MN

Allowable Costs / Cost Principles HUD Housing Programs Internal Control / Segregation of Duties

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 Audit 354912

Finding 558066 (2024-001)

Significant Deficiency 2024

Smithsonian Institution

DC

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303

The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum...

The Smithsonian agrees with the finding. The Smithsonian would like to add that the reports were delivered to the sponsor and that the sponsor was satisfied with them. Furthermore, the sponsor has provided written acknowledgment that they were “verbally kept up to date” by the National Postal Museum (NPM) regarding this potential delay. Moving forward, NPM will strengthen senior management oversight of report delivery, review due dates more rigorously, and enhance internal controls to ensure timely submission. Any potential delays will be confirmed in writing to the sponsor ahead of the due date, and compliance updates will be provided by NPM senior management to the sponsor on a regular basis. Additionally, NPM will establish procedures to cross train staff to perform required responsibilities applicable to the NPM Project.

View Audit 354905

Finding 558043 (2024-029)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.303 § 200.403 § 200.77

Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have th...

Federal Fund Source liquidation is monitored monthly via the Fund Source Reconciliation Report and the Provider Utilization Report. Requests to close purchase orders associated with expiring federal fund sources are submitted to OPC accordingly. The Federal Financial Reporting Group will now have the right to close purchase orders with federal fund sources to expedite this process. Also, the Provider Utilization Report has been updated with Key Performance Indicators (KPIs), Contract End Date Exceeds Period of Performance and Payments Exceed Period of Performance, that specifically address the period of performance as of December 2024.

View Audit 354902 Questioned Costs: $1

Finding 558041 (2024-030)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.303

Formal internal control processes have been established for the Federal Funding Accountability and Transparency Act (FFATA) reporting, FFATA Preparation and Submission, 17-102. Additionally, FFATA review and approval has been delineated appropriately between the Director of Finance, Grants Manager, ...

Formal internal control processes have been established for the Federal Funding Accountability and Transparency Act (FFATA) reporting, FFATA Preparation and Submission, 17-102. Additionally, FFATA review and approval has been delineated appropriately between the Director of Finance, Grants Manager, and Federal Funds Accountant.

View Audit 354902

Finding 557725 (2024-028)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon ...

DCH will review MO 598348 within the Gateway system to ensure the established interface process is functioning properly. DCH will draft additional guidance through a policy memo to revise DHS policy 2750 as it relates to the processing of Ex-Parte members. The DCH policy memo will clarify that upon the completion of the determination by DHS, Gateway will notify GAMMIS of A/R's approval or denial thorough daily interface files sent from Gateway to GAMMIS. The non-confirmation report will be reviewed to determine SOP and validate that the file has been received. Additionally, the DCH policy memo will require Gateway to complete the DMA-962 and submit to Gainwell for manual processing if the file has not been received. DCH is also reviewing current policy to determine if the infinity date established for Ex-Parte members can be revised to a time-limited date.

View Audit 354902 Questioned Costs: $1

Finding 557724 (2024-024)

Significant Deficiency 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Allowable Costs / Cost Principles § 200.303 § 200.53

The Department acknowledges that some of the capitation rates in Georgia Medicaid Management Information System (GAMMIS) were inaccurate. The Department has completed the review of all capitation rates in GAMMIS from July 1, 2021. The Department is holding the rates currently in GAMMIS until the Cen...

The Department acknowledges that some of the capitation rates in Georgia Medicaid Management Information System (GAMMIS) were inaccurate. The Department has completed the review of all capitation rates in GAMMIS from July 1, 2021. The Department is holding the rates currently in GAMMIS until the Centers for Medicare and Medicaid Services (CMS) approves all the pending rate amendments.

View Audit 354902

Finding 557720 (2024-027)

Material Weakness 2024

State of Georgia/state Accounting Office-Ein Noted

GA

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

DCH will develop a reconciliation process between members denied within Georgia Gateway and members removed within GAMMIS. DHS will provide training as outlined within the current contract to address changes and updates to Medicaid policy and the Georgia Gateway system.

View Audit 354902 Questioned Costs: $1

Corrective Action Plans

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