Corrective Action Plans

Finding 564087 (2023-004)

None 2023

NC

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2023-004 Activities Allowed or Unallowed – Interprogram Activity Public and Indian Housing – CFDA Number 14.850 Other Matters, Questioned Costs Condition: The Authority has loaned monies from the Public and Indian Housing Program to the COCC. As of September 30, 2023 these loans totaled $349,352. ...

2023-004 Activities Allowed or Unallowed – Interprogram Activity Public and Indian Housing – CFDA Number 14.850 Other Matters, Questioned Costs Condition: The Authority has loaned monies from the Public and Indian Housing Program to the COCC. As of September 30, 2023 these loans totaled $349,352. Recommendation: The Authority should develop a plan based on budgeting and monitoring of COCC expenses to have the ability to reimburse funds to the Public and Indian Housing Program. Action Taken: To restore financial integrity and ensure proper use of COCC funds, the Authority will take the following actions: 1. COCC Optimization and Budget Reform: Develop and implement a proper, balanced COCC budget that reflects actual operating costs and allocates shared services appropriately. Establish budget accountability protocols, including monthly budget-to-actual reviews and variance reporting to the CFO, CEO, and Board. 2. Training and Capacity Building: Provide training for finance staff on COCC operations, HUD’s Asset Management model, and best practices for cost allocation and shared services. Engage external consultants to support financial modeling and long-term sustainability planning for RAD and LIHTC properties. 3. Shared Services Agreement: Formalize a Consulting and Shared Services Agreement to ensure that COCC services are appropriately billed and reimbursed by other programs. Monitor inter-program transactions to ensure compliance with HUD’s financial management requirements. 4. Salary Allocation and Cost Tracking: Conduct a salary allocation study to ensure that staff time is distributed adequately across programs. Implement time-tracking tools and cost allocation methodologies that align with HUD guidance and OMB Uniform Guidance. Effective Date: June 3, 2025 Contact Information Dr. Michael C. Threatt, Chief Executive Officer Sanford Housing Authority 317 Chatham Street Sanford, North Carolina 27330 (919) 776-7655

View Audit 358177 Questioned Costs: $1

Finding 564086 (2023-003)

Material Weakness 2023

Sanford Housing Authority

NC

Procurement, Suspension & Debarment HUD Housing Programs

2023-003 Special Tests and Provisions – Wage Rate Requirements 14.872 Public Housing Capital Fund Material Weakness in Internal Control, Material Noncompliance Condition: Only one contract funded by the Capital Fund Program was awarded during the audit period above the small purchase threshold. ...

2023-003 Special Tests and Provisions – Wage Rate Requirements 14.872 Public Housing Capital Fund Material Weakness in Internal Control, Material Noncompliance Condition: Only one contract funded by the Capital Fund Program was awarded during the audit period above the small purchase threshold. The contract did not contain the required wage rate clause, and the Authority was not able to provide documentation showing that the contractor had submitted the required certified payrolls. Recommendation: We recommend that the Authority ensure the required wage rate clause is included in all contracts above $2,000 and that certified payrolls are being submitted and documentation retained. Action Taken: To address these deficiencies, the Authority will implement the following corrective action: 1. Staff Training: Provide targeted training for procurement, contract management, and asset management staff on Davis-Bacon wage requirements, certified payroll review, and labor compliance monitoring. Incorporate Davis-Bacon compliance into the Authority’s procurement and contract management SOPs. 2. Vendor Compliance Monitoring: Require all contractors and subcontractors to submit certified payrolls electronically. Establish a formal review process to verify wage classifications, hours worked, and compliance with prevailing wage rates. Conduct periodic wage interviews and maintain documentation in accordance with HUD and Department of Labor guidelines. 3. Payroll Analysis and Internal Controls: Assign a designated compliance officer or staff member to oversee wage rate compliance and maintain a centralized log of all Davis-Bacon projects. Implement a checklist and audit trail for each project to ensure all required documentation is collected and reviewed prior to payment authorization.

View Audit 358177

Finding 564085 (2023-002)

Material Weakness 2023

Sanford Housing Authority

NC

Questioned Costs Procurement, Suspension & Debarment § 200.320

2023-002 Procurement and Suspension and Debarment – Proper Documentation 14.872 Public Housing Capital Fund Material Weakness in Internal Control, Material Noncompliance Condition: The Authority did not have adequate controls over compliance with federal regulations regarding procurement. During ...

2023-002 Procurement and Suspension and Debarment – Proper Documentation 14.872 Public Housing Capital Fund Material Weakness in Internal Control, Material Noncompliance Condition: The Authority did not have adequate controls over compliance with federal regulations regarding procurement. During the audit period, Authority paid amounts to a contractor for unit turnover and renovation totaling $121,125 without documenting that it had properly procured these services. Recommendation: Authority personnel responsible for acquiring goods and services should receive additional training regarding the federal standards for procurement. Action Taken: To address the identified deficiencies and restore compliance, the Authority will implement the following corrective actions: 1. Training and Capacity Building: Provide comprehensive online and in-person training on procurement, contract management, and budget accountability for all relevant staff. Train management staff on participating in procurement selection committees and evaluating Requests for Proposals (RFPs), Requests for Quotations (RFQs), and Invitations for Bids (IFBs). Include budget literacy and financial planning modules in all staff training programs to ensure understanding of budget development, monitoring, and compliance. 2. Third-Party Assessment and Policy Updates: Engage a third-party firm to assess procurement, contract management, and budget oversight operations. Revise the current procurement policy, standard operating procedures (SOPs), and budget management protocols to ensure alignment with best practices. Update internal controls and financial policies to ensure alignment with HUD regulations and best practices. 3. Process Improvement and Technology Integration: Develop a process map based on assessment findings to streamline procurement and budget workflows, thereby reducing risk. Implement an affordable, user-friendly eProcurement software solution tailored to the affordable housing sector. Evaluate the need for a dedicated staff member to manage the eProcurement system, including vendor management, proposal evaluation, contract oversight, reporting, and system integration. 4. Transparency and Outreach: Create and maintain a procurement page on both the current and new Authority websites. Publicize procurement opportunities through social media and other outreach channels. Publish budget summaries and procurement plans to promote transparency and stakeholder confidence. 5. Governance and Accountability: Ensure all relevant staff, including finance, executive leadership, asset management, and others, are trained in procurement, contract management, and budget accountability. Reinforce best practices by designating the Chief Executive Officer as the sole Contracting Officer authorized to enter into agreements on behalf of the Authority. Establish regular internal audits and budget reviews to monitor compliance and performance.

View Audit 358177 Questioned Costs: $1

Finding 564084 (2023-001)

Material Weakness 2023

Sanford Housing Authority

NC

HUD Housing Programs Material Weakness Reporting

2023-001 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 – Housing Choice Vouchers Material Weakness in Internal Control, Material Noncompliance Condition: The Authority’s audited Financial Data Schedule...

2023-001 Reporting – Late REAC Submission and Late OMB Data Collection Form Submission Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 – Housing Choice Vouchers Material Weakness in Internal Control, Material Noncompliance Condition: The Authority’s audited Financial Data Schedule (“FDS”) filing was not submitted within the timeframes specified by HUD. The FDS filing was due by June 30, 2024, but the financials were not issued until June 3, 2025. The Authority was also required to submit the OMB Data Collection Form to the Federal Audit Clearinghouse (“FAC”) by June 30, 2024, but was not filed timely as the audit was completed on June 3, 2025. Recommendation: The Authority should ensure that they retain support for all required documentation and that it is organized and readily accessible. Storing documents electronically with frequent backups would help prevent loss of data from damage to any one location. Furthermore, the Authority should ensure that staff receives necessary training for proper document retention. Action Taken: To address the identified deficiencies and restore compliance with HUD requirements and the Trouble Recovery Agreement, the Authority will implement the following corrective actions: 1. Leadership and Governance Stabilization: Ensure that the new CEO is briefed on all relevant programs, financial updates, management, and strategic planning initiatives. Ensure that the Finance Committee, within the Board of Commissioners, continues to hold monthly meetings before all regular board meetings and monitors financial reporting, budget adherence, and audit readiness. Ensure that the Administrative Plan for the HCV Program is comprehensively updated to reflect current HUD regulations and strategies for program optimization. 2. Financial Staffing and Capacity Building: Maintain continuity in financial leadership by supporting the Interim CFO and ensuring adequate staffing, such as the new Staff Accountant in the Finance Department, to support audit preparation and HUD reporting. Develop a financial onboarding and training program for all new finance staff, with a focus on HUD systems (FDS, VMS, EPIC, LOCCS) and internal budget protocols. Ensure that Program and Finance Management staff of the HCV Program attend the HCV Financial Management and HCV Financial Accounting and Reporting sessions. 3. Budget Training and Accountability: Implement mandatory budget training for the Finance Department and the HCV Program Department, covering: Budget development and forecasting; Budget-to-actual variance analysis; HUD funding streams and eligible uses; Internal budget controls and documentation standards; Voucher Management System, FDS policies, and SOPs. Create an Accountability Chart for the Program and Financial Management of the HCV Program, outlining roles, responsibilities, and procedures for budget planning, monitoring, and reporting. Require monthly or biweekly meetings with budget reviews by department heads and mid-level managers, with variance explanations submitted to the CFO and CEO, and shared with the Board. 4. Fee Accountant Reinstatement and Optimize HCV Program Finances: Reinstate and formalize the partnership with BDO PHA Finance to support audit preparation, financial reporting, and staff training. Establish financial performance tracking, standard operating procedures (SOPs), contract compliance monitoring, and payment authorization protocols. 5. Technology and Data Management Improvements: Prepare the Chart of Accounts, Procure to Pay, and Voucher Management System (VMS), as well as the Two-Year Tool (TYT), and take other necessary financial steps to ensure a seamless transition from SACS to Reframe. Implement cloud-based storage and digital backup protocols to safeguard financial records and ensure continuity in the event of future disruptions. Establish a centralized digital archive for all financial documents, including budgets, invoices, contracts, and audit work papers. 6. Audit Readiness and Compliance Monitoring: Create an annual audit preparation calendar with clear deadlines for data collection, reconciliations, and internal reviews. Conduct monthly and quarterly internal audits to assess financial controls, procurement compliance, and budget adherence. Submit monthly and quarterly progress reports to HUD and the Board as part of the Troubled Recovery Agreement and internal HUD Recovery Strategic Plan, documenting improvements in financial management and audit readiness. 7. Transparency and Communication: Present monthly financial reports to the Board of Commissioners, including budget-to-actual comparisons and audit status updates. Publish an annual financial summary on the Authority’s website to promote transparency and public accountability

View Audit 358177

Finding 564006 (2023-003)

Significant Deficiency 2023

Supporting Families Together Association, Inc.

WI

Reporting § 200.512

Thriving WI has made significant enhancements to its accounting team in both experience and depth of knowledge by outsourcing accounting functions to a third party provider with experience in this reporting. Additionally processes and procedures to support planning, performing and completing the aud...

Thriving WI has made significant enhancements to its accounting team in both experience and depth of knowledge by outsourcing accounting functions to a third party provider with experience in this reporting. Additionally processes and procedures to support planning, performing and completing the audit on time are utilized and have been in effect since January 1, 2024.

View Audit 358160

Finding 564003 (2023-006)

Significant Deficiency 2023

City of Tishomingo, Oklahoma

OK

Reporting Matching / Level of Effort / Earmarking

The City will periodically review all expenditures of federal awards including subawards received in partnership with the Chickasaw Nation.

View Audit 358159

Finding 563996 (2023-005)

Material Weakness 2023

City of Tishomingo, Oklahoma

OK

Reporting § 200.512

The City will attempt to file all reporting packages in accordance with 2 CFR 200.512(a).

View Audit 358159

Finding 563931 (2023-013)

Significant Deficiency 2023

Barclay College

KS

Student Financial Aid Cash Management

Cash Management Planned Corrective Action: The reconciliation process will be reviewed and any deficiencies will be corrected to assure funding is drawn and disbursed within three days of receipt. Student disbursement reports will be reviewed to determine drawdown amounts before making draws from G5...

Cash Management Planned Corrective Action: The reconciliation process will be reviewed and any deficiencies will be corrected to assure funding is drawn and disbursed within three days of receipt. Student disbursement reports will be reviewed to determine drawdown amounts before making draws from G5. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563926 (2023-012)

Material Weakness 2023

Barclay College

KS

Subrecipient Monitoring Material Weakness

Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: We will review items not fully implemented. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563922 (2023-011)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Material Weakness

Return of Title IV (R2T4) Planned Corrective Action: A process will be implemented to run a 0-credit report at the end of each semester. This will ensure withdrawals are followed up on and that R2T4s are completed timely, if required. A process will be implanted to track student attendance in class...

Return of Title IV (R2T4) Planned Corrective Action: A process will be implemented to run a 0-credit report at the end of each semester. This will ensure withdrawals are followed up on and that R2T4s are completed timely, if required. A process will be implanted to track student attendance in classes. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563920 (2023-010)

Material Weakness 2023

Barclay College

KS

Reporting Student Financial Aid Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lee Anders, Vice Pr...

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563919 (2023-009)

Material Weakness 2023

Barclay College

KS

Questioned Costs Student Financial Aid Eligibility

Incorrect Pell Calculations Planned Corrective Action: A process will be implemented to verify Pell is correctly awarded before disbursements are made. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096 Questioned Costs: $1

Finding 563918 (2023-008)

Material Weakness 2023

Barclay College

KS

Questioned Costs Student Financial Aid Material Weakness

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Da...

Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096 Questioned Costs: $1

Finding 563916 (2023-007)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Enrollment Reporting to NSLDS Planned Corrective Action: A process will be created to ensure enrollment is reported timely and accurately. Spot checks of NSLDS will be performed on enrollment status throughout the year. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for B...

Enrollment Reporting to NSLDS Planned Corrective Action: A process will be created to ensure enrollment is reported timely and accurately. Spot checks of NSLDS will be performed on enrollment status throughout the year. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563911 (2023-006)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Eligibility Material Weakness

ISIR Comment Resolution Planned Corrective Action: All ISIR comment codes will be resolved before disbursement of federal aid to students. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563906 (2023-005)

Material Weakness 2023

Barclay College

KS

Eligibility Student Financial Aid Material Weakness

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09...

Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563901 (2023-004)

Material Weakness 2023

Barclay College

KS

Student Financial Aid Material Weakness

Lack of Administrative Capability Planned Corrective Action: The financial aid officer will participate in trainings specific to knowledge gaps. In addition, monthly entries will be made in the general ledger for financial aid activity and monthly balances will be reconciled between the general ledg...

Lack of Administrative Capability Planned Corrective Action: The financial aid officer will participate in trainings specific to knowledge gaps. In addition, monthly entries will be made in the general ledger for financial aid activity and monthly balances will be reconciled between the general ledger and financial aid software. Person Responsible for Corrective Action Plan: Lee Anders, Vice President for Business Services Anticipated Date of Completion: 09/30/25

View Audit 358096

Finding 563891 (2023-001)

Material Weakness 2023

Camden Redevelopment Agency

NJ

Reporting

Criteria Management is responsible for timely and accurate financial reporting. Condition Identified: Various reconciliations, adjustments, and year-end close procedures were not completed in a timely and accurate manner, resulting in a delay in the completion of the annual audit and untimely filin...

Criteria Management is responsible for timely and accurate financial reporting. Condition Identified: Various reconciliations, adjustments, and year-end close procedures were not completed in a timely and accurate manner, resulting in a delay in the completion of the annual audit and untimely filing of the required Single Audit Data Collection Form. Corrective Action Plan • Implementation of a Year-End Close Calendar: Develop and adopt a comprehensive year-end close calendar with specific deadlines and responsibilities for each required task, including reconciliations, adjustments, and audit preparation. This calendar will be communicated to all relevant personnel at least 60 days before fiscal year-end. • Monthly Reconciliation Schedule: Enforce a standardized monthly reconciliation process for all key accounts (e.g., cash, receivables, payables, grants), to ensure that year-end tasks do not accumulate and can be completed efficiently and accurately. • Staff Training and Cross-Training: Provide targeted training for accounting and finance staff on proper reconciliation techniques, closing procedures, and audit requirements. Cross-training will also be provided to ensure continuity and reduce reliance on single individuals. • Audit Preparation Checklist: Create and utilize an internal audit prep checklist that is reviewed quarterly and finalized before year-end. This will ensure all necessary reports, schedules, and documentation are prepared well in advance of the auditor’s arrival. • Automation and Software Improvements: Evaluate and implement improvements in accounting software or systems to automate reconciliation reports and reduce the risk of manual errors. • Ongoing Monitoring: The Finance Director will perform monthly reviews of account reconciliations and quarterly mock close-outs to assess timeliness and accuracy. Issues will be flagged early for resolution. Responsible Person(s): Chief Executive Officer, Finance Director, & Senior Accountant Anticipated Completion Date: All corrective measures will be implemented (insert date) in preparation for the FY 2024 year-end.

View Audit 358094

Finding 563845 (2023-003)

Significant Deficiency 2023

Global Fund to End Modern Slavery

DC

Reporting Subrecipient Monitoring

2023-003 – Reporting Management’s Corrective Action Plan: The federal subaward in question had been mistakenly recorded as a non-USG government grant in the Fund's accounting records by previous Fund financial teams in 2022. As a result, it was omitted from the SEFA. This will not happen in 2024.

View Audit 358064

Finding 563841 (2023-004)

Significant Deficiency 2023

Global Fund to End Modern Slavery

DC

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month p...

2023-004 – Allowable Costs relating to Time and Effort and Internal Controls Management’s Corrective Action Plan: Management agrees with the Federal award finding identified in the audit. We acknowledge that a few timesheets and spreadsheets were missing from appropriate files during a two-month period of transition at the Fund, while maintaining that proper allocation process was followed up to the point of record keeping. The Fund understands the reasons for the missing timesheets and that these cases were unique and not indicative of the normal and prevalent internal control over the completion and approval of timesheets. The allocation of payroll for the months tested were based on the consistent and correct application of the payroll costs allocation methodology however in a limited number of cases the allocation spreadsheets weren’t properly saved. After announcement of dissolution, there was considerable staff turnover and rapid transition which created challenges and delays. We did maintain an effective control environment. This has been resolved. Management is saving allocation spreadsheets, and other required documentation as per policy on an ongoing basis.

View Audit 358064

Finding 563840 (2023-002)

Significant Deficiency 2023

Global Fund to End Modern Slavery

DC

Subrecipient Monitoring Reporting § 200.512

2023-002 – Submission of Data Collection Form Management’s Corrective Action Plan: Management agrees with the finding identified in the audit. The constraint of finance staffing limitations pushed the issuance of the audited financial statements past the September 30, 2024 deadline. We anticipate ...

2023-002 – Submission of Data Collection Form Management’s Corrective Action Plan: Management agrees with the finding identified in the audit. The constraint of finance staffing limitations pushed the issuance of the audited financial statements past the September 30, 2024 deadline. We anticipate meeting any filing deadlines in the future.

View Audit 358064

Finding 563813 (2023-002)

Significant Deficiency 2023

Trinity Housing CORP of Greeley

CO

Subrecipient Monitoring

Name of auditee: Trinity Housing Corporation of Greeley HUD auditee identification number: 101-98145 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended October 31, 2023 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Tel...

Name of auditee: Trinity Housing Corporation of Greeley HUD auditee identification number: 101-98145 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended October 31, 2023 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2023-002 Comments on the Finding and Each Recommendation: The Corporation did not furnish Form SF-SAC Single Audit Data Collection Form for the years ended October 31, 2023 was not submitted to the federal audit clearinghouse in the required timeframe. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. The audited financial statements will be submitted to the federal audit clearinghouse.

View Audit 358034

Finding 563812 (2023-001)

Significant Deficiency 2023

Trinity Housing CORP of Greeley

CO

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Name of auditee: Trinity Housing Corporation of Greeley HUD auditee identification number: 101-98145 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended October 31, 2023 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Tel...

Name of auditee: Trinity Housing Corporation of Greeley HUD auditee identification number: 101-98145 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended October 31, 2023 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2023-001 Comments on the Finding and Each Recommendation: For the year ended October 31, 2023, the Corporation paid management fees to the Agent in excess of the fees earned resulting in prepaid management fees of $8,370 at October 31, 2023. Action(s) taken or planned on the finding: The Corporation concurs with the finding and agrees with the auditor’s recommendation.

View Audit 358034 Questioned Costs: $1

Finding 563805 (2023-004)

Significant Deficiency 2023

Taylor Regional Hospital, Inc.

GA

Significant Deficiency Matching / Level of Effort / Earmarking

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2023. The findings from the March 31, 2023 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the ...

Taylor Regional Hospital (Hospital) respectfully submits the following corrective action plan for the year ended March 31, 2023. The findings from the March 31, 2023 Schedule of Findings and Questioned Costs is discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDINGS Significant Deficiency (2023-004) Recommendation: The Hospital should immediately fund the Reserve Account to the proper funding level required by the USDA loan. Planned Corrective Action: The hospital agrees with this finding. See 2023-002.

View Audit 358013

Finding 563782 (2023-009)

Significant Deficiency 2023

County of Montgomery

PA

Questioned Costs Reporting § 200.303 § 200.502 § 200.510

2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of H...

2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ARPA expenditures, multiple transactions were identified as 2022 fiscal year expenditures that were included in the 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

View Audit 357994 Questioned Costs: $1

Corrective Action Plans

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