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Corrective Action Plans

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Finding 1157410 (2024-009)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Procurement, Suspension & Debarment
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-009: • Heart City Health Center, Inc. continues to improve its procurement policies where necessary and will make sure further steps are introduced to increase documentation around it...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-009: • Heart City Health Center, Inc. continues to improve its procurement policies where necessary and will make sure further steps are introduced to increase documentation around its procurement policies • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664
Finding 1157409 (2024-008)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Questioned Costs Matching / Level of Effort / Earmarking Cash Management
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-008: • Heart City Health Center, Inc. will improve its understanding on matching principles on federal grant programs to ensure proper compliance with future grants • Heart City Healt...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-008: • Heart City Health Center, Inc. will improve its understanding on matching principles on federal grant programs to ensure proper compliance with future grants • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664 Questioned Costs: $1
Finding 1157408 (2024-007)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Questioned Costs Allowable Costs / Cost Principles Cash Management
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-007: • Heart City Health Center, Inc. will continue to improvement knowledge and understanding of grant requirements as / if new funding is received to avoid allocating unallowed expe...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-007: • Heart City Health Center, Inc. will continue to improvement knowledge and understanding of grant requirements as / if new funding is received to avoid allocating unallowed expenses to the grant reimbursement • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664 Questioned Costs: $1
Finding 1157407 (2024-006)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Reporting
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664
Finding 1157403 (2024-005)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-005: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period
View Audit 369664 Questioned Costs: $1
Finding 1157399 (2024-004)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Questioned Costs Cash Management
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-004: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-004: • Heart City Health Center, Inc. will refine and change controls that deal with tracking of when expenses are incurred to confirm that no drawdown receipt is received before then or in the incorrect grant period
View Audit 369664 Questioned Costs: $1
Finding 1157395 (2024-003)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Questioned Costs Allowable Costs / Cost Principles
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-003: • Heart City Health Center, Inc. continues to focus on the preparation and review process around cost allocation to the multiple different funding sources to ensure no future dup...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-003: • Heart City Health Center, Inc. continues to focus on the preparation and review process around cost allocation to the multiple different funding sources to ensure no future duplication
View Audit 369664 Questioned Costs: $1
Finding 1157391 (2024-001)
Material Weakness 2024
The Center for Independent Documentary, Inc.
MA
Procurement, Suspension & Debarment § 200.214 § 200.322
CORRECTIVE ACTION PLAN September 25, 2025 Cognizant or Oversight Agency for Audit The Center for Independent Documentary, Inc. (the Center) respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAs,...
CORRECTIVE ACTION PLAN September 25, 2025 Cognizant or Oversight Agency for Audit The Center for Independent Documentary, Inc. (the Center) respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington Street Westborough, MA 01581 Audit period: January 1, 2024 – December 31, 2024 The finding from the December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS 2024-001 Procurement Policy Recommendation: We recommend that management establish a formal procurement consistent with the procurement standards set forth in the Uniform Guidance (2 CFR 200.317–327) issued by the U.S. Office of Management and Budget (OMB). Action Taken: We will work with the Board of Directors to establish a formal procurement policy that will include the following: • We will formalize procedures to confirm vendor eligibility, including consistent use of the SAM.gov exclusions list prior to entering contracts, and ensure documentation is retained for audit purposes. • The updated policy will outline specific steps for procurement activities at various thresholds, particularly mid-range purchases, with requirements for obtaining multiple quotes and documenting price comparisons. • In alignment with Federal guidelines, the revised policy will include a provision supporting preference for U.S.-made products and materials when feasible. • New sections will be added to address how the Center will manage vendor selection reviews, disputes, and issue resolution to promote fairness and consistency in the procurement process. • To ensure transparency and version control, the policy will include the date of each revision and a process for periodic review. The Center’s Management will implement the updated policy, coordinate training for programmatic staff, and monitor compliance with the updated procedures. We expect the revised procurement policy to be finalized and implemented by December 15, 2025. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Susan Walsh, at 339-364-1277. Sincerely yours, Susan Walsh Executive Director
View Audit 369655
Finding 1157390 (2024-003)
Material Weakness 2024
Educare of Omaha, Inc.
NE
Cash Management Eligibility Material Weakness § 200.303
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025
View Audit 369654
Finding 1157389 (2024-004)
Material Weakness 2024
Lincoln County, Nebraska
NE
Procurement, Suspension & Debarment
The County Clerks office will review all claims submitted against federal funds will have the attached vendor verification through SAM.gov at the time of submittal. If the required documentation is not attached, it will be returned to the claimant. The Lincoln County Board of Comissioners will also ...
The County Clerks office will review all claims submitted against federal funds will have the attached vendor verification through SAM.gov at the time of submittal. If the required documentation is not attached, it will be returned to the claimant. The Lincoln County Board of Comissioners will also review all claims prior to board approval for the necessary documentation against federal funds.
View Audit 369653
Finding 1157388 (2024-003)
Material Weakness 2024
Lincoln County, Nebraska
NE
Reporting Internal Control / Segregation of Duties
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
View Audit 369653
Finding 1157387 (2024-008)
Material Weakness 2024
Northwest Side Housing Center
IL
Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.305
The Center is working on paying off its vendors of which older payables are still outstanding, and will establish procedures to ensure timely disbursement of funds upon receipt to vendors going forward.
The Center is working on paying off its vendors of which older payables are still outstanding, and will establish procedures to ensure timely disbursement of funds upon receipt to vendors going forward.
View Audit 369652
Finding 1157386 (2024-007)
Material Weakness 2024
Northwest Side Housing Center
IL
Reporting Matching / Level of Effort / Earmarking § 200.510
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
View Audit 369652
Finding 1157385 (2024-006)
Material Weakness 2024
Northwest Side Housing Center
IL
Cash Management Reporting Internal Control / Segregation of Duties
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
View Audit 369652
Finding 1157380 (2024-005)
Material Weakness 2024
Northwest Side Housing Center
IL
Procurement, Suspension & Debarment § 200.212 § 200.318
Going forward the Center will prepare and implement a procurement policy in accordance with Uniform Guidance requirements and ensure there is documentation that verifies vendors are not suppressed or debarred prior to entering into contracts with the vendors.
Going forward the Center will prepare and implement a procurement policy in accordance with Uniform Guidance requirements and ensure there is documentation that verifies vendors are not suppressed or debarred prior to entering into contracts with the vendors.
View Audit 369652
Finding 1157375 (2024-004)
Material Weakness 2024
Northwest Side Housing Center
IL
Cash Management Reporting
The Center is implementing reconciliations of the grant expenditures to the general ledger.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
View Audit 369652
Finding 1157370 (2024-003)
Material Weakness 2024
Northwest Side Housing Center
IL
Questioned Costs Internal Control / Segregation of Duties § 200.430
The Center has implemented time and effort reports in the subsequent year to properly substantiate each employee's time and effort spent on each grant.
The Center has implemented time and effort reports in the subsequent year to properly substantiate each employee's time and effort spent on each grant.
View Audit 369652 Questioned Costs: $1
Finding 1157367 (2024-005)
Material Weakness 2024
Keystone Restituere Justice Center, Inc.
PA
Subrecipient Monitoring § 200.332
Finding number 2024-005, material weakness in internal controls over compliance – subrecipient monitoring. Recommendation: We recommend that management implement procedures to ensure that all subrecipient agreements include the information required by 2 CFR 200.322. This should include a standardize...
Finding number 2024-005, material weakness in internal controls over compliance – subrecipient monitoring. Recommendation: We recommend that management implement procedures to ensure that all subrecipient agreements include the information required by 2 CFR 200.322. This should include a standardized checklist or template for subaward agreements and periodic reviews to verify compliance. We further recommend the entity implement and document procedures to (1) perform and retain evidence of subrecipient risk assessments, and (2) verify and document whether sub-recipients are subject to the Since Audit and, if so, obtain and review the audit reports for findings related to the federal program. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: KRJC will develop a standardized checklist for all subaward agreements and will conduct semi-annual reviews to verify compliance with that checklist. As part of this updated review, KRJC will perform updated risk assessments with all sub-awardees and will retain evidence of those risk assessments in sub-awardee files. KRJC will also verify and document whether sub-recipients are subject to the single audit, and, if so, obtain and review the audit reports for findings related to the federal program. KRJC will ensure that any existing sub-awardees are reviewed for compliance no later than November 1, 2025. Planned completion date for corrective action plan: November 1, 2025.
View Audit 369651
Finding 1157366 (2024-004)
Material Weakness 2024
Keystone Restituere Justice Center, Inc.
PA
Reporting § 200.328
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timefr...
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timeframes. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: KRJC has now developed a clear procedure for ensuring that all program expenses are received and/or accrued for the period so that reporting can be completed and submitted no later than 30 days after the end of the quarter. All FFY2025 required financial and narrative reporting has been submitted within the required time frame. Planned completion date for corrective action plan: November 30, 2024.
View Audit 369651
Finding 1157365 (2024-003)
Material Weakness 2024
Keystone Restituere Justice Center, Inc.
PA
Procurement, Suspension & Debarment § 200.214
Finding number 2024-003, significant deficiency in internal controls over compliance – procurement. Recommendation: We recommend that the Organization implement one of the following procedures to verify and document that vendors are not on the suspended or debarred list: 1) checking the System for A...
Finding number 2024-003, significant deficiency in internal controls over compliance – procurement. Recommendation: We recommend that the Organization implement one of the following procedures to verify and document that vendors are not on the suspended or debarred list: 1) checking the System for Award Management (SAM) Exclusions and maintain a printout of that as documentation of the check; 2) collecting a separately executive certification from the entity; or 3) adding a clause to the consulting agreement with the vendor. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: While KRJC actually completed all debarment checks prior to funding any sub-awardees, this was done without documenting these checks for the organization’s files. In the past this was done by checking the System of Award Management. However, these searches were not documented in the consultant files. While KRJC will continue to conduct screenings on SAM, as of September 20, 2025, KRJC has adopted a new policy, where all sub-awardees, are required, as an element of their consulting agreement, to certify that they have been neither debarred nor suspended. Note: Several of KRJC’s sub-awardees in place as of December 31, 2024, were operating under existing contracts. For these sub-awardees, KRJC has required the sub-awardee to submit a separate document certifying that they have been neither debarred nor suspended. Planned completion date for corrective action plan: September 30, 2025.
View Audit 369651
Finding 1157364 (2024-002)
Material Weakness 2024
Keystone Restituere Justice Center, Inc.
PA
Cash Management § 200.303 § 200.305
Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Findi...
Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: In April of 2024, KRJC established a financial policy that ensures that funds are only drawn down for expenses incurred and/or accrued during the reporting period. All expenses are booked into KRJC’s accounting system. KRJC then calculates any funding due from BJA and then completes a draw down for any payments due. In an effort to ensure that funds are never overdrawn but that KRJC can pay sub-awardees and contracts in a timely manner, this process may occur multiple times in any given quarter. In addition, KRJC has worked to develop a pool of unrestricted funds and is working to develop an operating reserve, using private funds, that will allow the organization some additional flexibility in our financial operations and will ultimately allow KRJC to shift to quarterly drawdowns. Planned completion date for corrective action plan: July 2024
View Audit 369651
Finding 1157363 (2024-007)
Material Weakness 2024
Polk County
MN
Eligibility Internal Control / Segregation of Duties § 200.303
Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exist...
Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input into MAXIS. County Comment: A Corrective Action Plan has been established with an anticipated completion date of December 31, 2025. Anticipated Completion Date: December 31, 2025.
View Audit 369649
Finding 1157362 (2024-005)
Material Weakness 2024
Howard County Housing Commission
MD
Questioned Costs HUD Housing Programs Allowable Costs / Cost Principles
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Cash Disbursements Recommendation: We recommend that the Commission review its policies and procedures in place to ensure that only allowable activities are associated with the usage of program funding allocations. Explanation of disagreement with...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Cash Disbursements Recommendation: We recommend that the Commission review its policies and procedures in place to ensure that only allowable activities are associated with the usage of program funding allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The unallowable cash disbursement of $35.43 was promptly removed from the HCVP program and reallocated to the appropriate account. Additional cash disbursement samples were provided to the auditor for further testing to ensure compliance. Staff received training in allowable and unallowable administrative costs under the HCVP guidelines. To strengthen internal controls and prevent recurrence, a second-level review of accounting codes is now required for disbursements. Name(s) of the contact person(s) responsible for corrective action: Bei Hua, Chief Financial Officer Planned completion date for corrective action plan: October 2025 and ongoing If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Crystal Gorham at 443-518-7818 and Bei Hua at 443 518-7802 .
View Audit 369641 Questioned Costs: $1
Finding 1157361 (2024-004)
Material Weakness 2024
Howard County Housing Commission
MD
HUD Housing Programs
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Quality Control Inspections Recommendation: We recommend the Commission review their quality control procedures to ensure any unit used for quality control is inspected timely. Explanation of disagreement with audit finding: There is no disagreeme...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Quality Control Inspections Recommendation: We recommend the Commission review their quality control procedures to ensure any unit used for quality control is inspected timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCHC staff has set up procedures with the inspection company to ensure that quality control inspections are occurring every quarter, to ensure that an inspection takes place within 90 days of the first inspection. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Planned completion date for corrective action plan: January 2025 and ongoing
View Audit 369641
Finding 1157360 (2024-003)
Material Weakness 2024
Howard County Housing Commission
MD
Questioned Costs HUD Housing Programs Material Weakness
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – HQS Enforcement Recommendation: We recommend the Commission review their abatement procedures to ensure any unit that has not met the HQS standards is properly abated in cases of inspection deficiencies associated with landlord fault, and to revie...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – HQS Enforcement Recommendation: We recommend the Commission review their abatement procedures to ensure any unit that has not met the HQS standards is properly abated in cases of inspection deficiencies associated with landlord fault, and to review their procedures to enforce family obligations in cases of inspection deficiencies associated with tenant fault. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Review the inspection report weekly, to send out abatement letters, warning letters, and/or proposed termination letters to ensure compliance with HQS inspections. HCHC staff updated the internal process to ensure that inspection abatement letters are being sent to all parties, and when the deficiencies are tenant-related, the families are sent a warning letter and/or termination letter for non-compliance. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Planned completion date for corrective action plan: November 2025, and ongoing
View Audit 369641 Questioned Costs: $1
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