Corrective Action Plans

Finding 1175235 (2023-008)

Material Weakness 2023

AL

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract...

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract Number: 2302ORLIEA, 2202ORLIEA Grant period – 2022 & 2023 ORCCA is aware of lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants’ requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. The estimated date of completion of this process is January 31, 2026. ORCCA’s current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period.

View Audit 388923

Finding 1174702 (2023-013)

Material Weakness 2023

City of Woonsocket

RI

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174701 (2023-012)

Material Weakness 2023

City of Woonsocket

RI

Allowable Costs / Cost Principles Reporting Special Tests & Provisions

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174135 (2023-001)

Material Weakness 2023

HOMES OF MONTCLAIR ECUMENICAL CORP

NJ

Subrecipient Monitoring Eligibility HUD Housing Programs

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedure...

Management concurs with the finding. The Organization revised its tenant monitoring procedures to ensure timely annual recertification of income and compliance with HUD rent adjustment requirements. Training is being provided to all property management staff, and management has implemented procedures to ensure all required actions are taken when a tenant becomes over-income.

View Audit 387791

Finding 1174131 (2023-002)

Material Weakness 2023

Norman County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/train...

Finding Number: 2023-002 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Teri Taylor Corrective Action Planned: Implementation of quarterly internal auditing of cases Annual Public Assistance Program review/trainings for staff Anticipated Completion Date: Quarterly internal audits anticipated start date: April 2026 Anticipated completion date of ongoing program training: July 2026

View Audit 387778

Finding 1172735 (2023-003)

Material Weakness 2023

Town of Guilderland

NY

Procurement, Suspension & Debarment Eligibility Subrecipient Monitoring § 200.213 § 200.318

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We rec...

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We recommend that the Town review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. Corrective Action: Moving forward, the Town of Guilderland will ensure that vendors are not included on the suspended or debarred list to ensure compliance with the requirements noted above. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The practice noted above was implemented during September of 2024.

View Audit 386023

Finding 1171299 (2023-084)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Special Tests & Provisions § 200.303

DHS continues working with a vendor on the implementation of the Provider Enrollment Application (PEA). Beginning in February 2026, the vendor will assume responsibility for enrolling all USVI providers—both in-territory and out-of-territory. Their enrollment process will address the three bulleted ...

DHS continues working with a vendor on the implementation of the Provider Enrollment Application (PEA). Beginning in February 2026, the vendor will assume responsibility for enrolling all USVI providers—both in-territory and out-of-territory. Their enrollment process will address the three bulleted conditions.

View Audit 384576

Finding 1171293 (2023-078)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibil...

Currently, a Standard Operating Policies and Procedures (SOPPs) for certification and recertification procedures is being updated. Additionally, DHS hired a Program Integrity Director in August 2023 and Medical Eligibility Quality Control (MEQC) Reviewer in June 2025 also tasked with the responsibility of reviewing completed case files.

View Audit 384576

Finding 1171275 (2023-073)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Special Tests & Provisions Subrecipient Monitoring § 200.303

An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, in...

An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.

View Audit 384576

Finding 1171273 (2023-071)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

DHS remains in compliance with this finding from previous audit years, the untimely submission led to the issue in current year. To address this, a shared file will be established to ensure that the necessary information for each year is readily available for audit purposes.

View Audit 384576

Finding 1171270 (2023-068)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

The Department of Human Services (DHS) has introduced a checklist as an additional internal control measure to ensure compliance with Federal requirements for review of provider enrollment applications by the provider relations staff.

View Audit 384576

Finding 1171244 (2023-059)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Eligibility HUD Housing Programs § 200.303

The Government concurs with the auditor’s findings and recommendations. VIDE is committed to addressing issues related to the participation of private school children in the COVID-19 Education Stabilization Fund. OMB will develop and implement formal policies and procedures to ensure compliance with...

The Government concurs with the auditor’s findings and recommendations. VIDE is committed to addressing issues related to the participation of private school children in the COVID-19 Education Stabilization Fund. OMB will develop and implement formal policies and procedures to ensure compliance with federal regulations. This includes establishing guidelines and a schedule for timely consultations with nonpublic schools and collaborating with the Department of Education to ensure equitable per-pupil expenditures for both private and public school children.

View Audit 384576

Finding 1171215 (2023-043)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting docu...

VIDOL concurs with the auditor’s findings and recommendations. VIDOL has reviewed its policies and procedures and is working to provide staff training to ensure supporting documentation is secure and readily accessible. VIDOL will update its policies and procedures to ensure that all supporting documentation is certified by the UI Director or designee before a report is submitted to the grantor. VIDOL will provide a copy of the report along with supporting documentation to the Business Administration Unit for recordkeeping. VIDOL is implementing a RESEA case management system for reporting and program services, currently in the testing and configuration phase. This case management system will serve as the official system for documenting all services provided to RESEA claimants participating in the program.

View Audit 384576

Finding 1171213 (2023-041)

Material Weakness 2023

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Eligibility Internal Control / Segregation of Duties § 200.303

VIDOL concurs with the auditor’s findings and recommendations. An electronic record-keeping system for claims files is expected to be launched before the end of FY 2026, enhancing record retention. VIDOL is reviewing its record retention policy and procedures and will provide training to staff on pr...

VIDOL concurs with the auditor’s findings and recommendations. An electronic record-keeping system for claims files is expected to be launched before the end of FY 2026, enhancing record retention. VIDOL is reviewing its record retention policy and procedures and will provide training to staff on proper maintenance and retention of complete program files. VIDOL staff will collaborate with USDOL for technical assistance and data validation to ensure eligibility and record maintenance.

View Audit 384576

Finding 1170543 (2023-004)

Material Weakness 2023

County of Delaware

PA

Student Financial Aid Subrecipient Monitoring Eligibility

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to...

Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.

View Audit 383805

Finding 1168715 (2023-002)

Material Weakness 2023

State of Kosrae

FM

Eligibility

2023-02 We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This...

2023-02 We agree with this Finding. Henceforth, we will ask for the employment status of all new and continuing patients. Those who are employed will be required to provide their most recent W-2 form or their paycheck stub as proof of their income and eligibility for the sliding scale discount. This information will be kept in each patient’s file and will be updated on a regular basis to ensure the continued compliance of the WCHC to the discount policy. March 31, 2026 Ms. Irene Laabrug Chief, Division of Finance & Treasury (691) 350-2142 ilaabrug123@gmail.com

View Audit 380731

Finding 1167998 (2023-001)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024

View Audit 379692

Finding 1167985 (2023-004)

Material Weakness 2023

Lone Pine Paiute- Shoshone Reservation

CA

Eligibility Material Weakness Reporting § 200.329

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the award...

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the awarding agency as required. Corrective Action: The Tribe has hired a full-time bookkeeper along with a new fiscal consultant to assist the bookkeeper in journal entries, bank statements, etc. on a monthly basis. All required reporting will be done within 30 days of the end of reporting date. Anticipated date of completion: April 1, 2026.

View Audit 379637

Finding 1167399 (2023-003)

Material Weakness 2023

Compañia de Turismo de Puerto Rico

PR

Allowable Costs / Cost Principles Eligibility Procurement, Suspension & Debarment

Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the ...

Views of responsible officials: Before the approval of budget and the contract petition, the legal department will very if the vendors are excluded as a authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the company’s ability to comply with federal regulations and maintain responsible vendor relationships. Names of the contact persons responsible for the corrective action plan: Sra. Carmen Fernandez, Legal Advisory Director Completed date: This corrective action was implemented as of December 31, 2024.

View Audit 378468

Finding 1166987 (2023-004)

Material Weakness 2023

Corporacion Del Centro De Bellas Artes De Puerto Rico

PR

Eligibility Special Tests & Provisions Procurement, Suspension & Debarment

Action Item Title 2023-004 – Federal Award Findings Status (Open: In-process) Condition Inactive SAM Registration Impacting Eligibility The Corporation’s SAM registration expired on September 6, 2023. Identified root cause The Corporation has been unable to update the SAM’s registration due to probl...

Action Item Title 2023-004 – Federal Award Findings Status (Open: In-process) Condition Inactive SAM Registration Impacting Eligibility The Corporation’s SAM registration expired on September 6, 2023. Identified root cause The Corporation has been unable to update the SAM’s registration due to problems with the platform to correct their physical address. Grantee resolution plan After multiple attempts, the entity’s information was successfully validated on December 21, 2024. Completion date Corrected on December 21, 2024. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

View Audit 378038

Finding 1166491 (2023-006)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Eligibility Reporting § 200.328

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Manageme...

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Certification Title III Expenditures and Unobligated Funds by statutory deadline. This process should include clear assignment to responsibilities and retention of documentation as part of grant compliance records.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166324 (2023-008)

Material Weakness 2023

Dorchester County, Maryland

MD

Eligibility Matching / Level of Effort / Earmarking § 200.303

The County will implement procedures to ensure the approval process is documented.

View Audit 377392

Finding 1166285 (2023-002)

Material Weakness 2023

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 377361

Finding 1164261 (2023-010)

Material Weakness 2023

Bristlecone Family Resources

CA

Eligibility Material Weakness Reporting

Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025

View Audit 373603

Finding 1162975 (2023-003)

Material Weakness 2023

The Multi-Assistance Center at Morgan's Wonderland

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.512

Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps...

Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps to strengthen oversight and ensure future compliance. Knowledgeable personnel are now in place and have been made fully aware of all federal reporting requirements and deadlines. Management is actively developing formalized policies and procedures governing federal reporting, including a centralized compliance calendar, documented workflows, defined roles and responsibilities, and an internal review process prior to submission. These measures will be implemented by the first quarter of 2026.

View Audit 372574

Corrective Action Plans

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