Corrective Action Plans

Finding 573277 (2024-001)

Material Weakness 2024

Dennis-Yarmouth Regional School District

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Conduct annual training for grant managers, administrators, and business office staff on federal compliance, financial policies, and internal controls.

View Audit 364069

Finding 573277 (2024-001)

Material Weakness 2024

Dennis-Yarmouth Regional School District

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Update and distribute grants and finance-related policies annually. Maintain acknowledgement forms from relevant staff.

View Audit 364069

Finding 573277 (2024-001)

Material Weakness 2024

Dennis-Yarmouth Regional School District

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Conduct a self-assessment or internal audit of grant compliance and internal controls. Make adjustments based on findings.

View Audit 364069

Finding 573274 (2024-003)

Significant Deficiency 2024

Sunrise Residential, Inc.

IL

Questioned Costs HUD Housing Programs Matching / Level of Effort / Earmarking

Finding Reference Number: 2024-03 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure cash disbursements of project funds are limited to project operating costs. Expens...

Finding Reference Number: 2024-03 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure cash disbursements of project funds are limited to project operating costs. Expense paid from project funds for an affiliated project will be reimbursed to the project. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Billie Williams, President of Active Real Estate Management Completion Date: Open

View Audit 364065

Finding 573272 (2024-002)

Significant Deficiency 2024

Sunrise Residential, Inc.

IL

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP con...

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP contract. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Billie Williams, President of Active Real Estate Management Completion Date: Open

View Audit 364065

Finding 573214 (2024-002)

Material Weakness 2024

East Phillips CO Hospital Dist Dba Melissa Memorial Hospital

CO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses...

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses to verify that they are appropriate and in the correct accounting period. A procedure will be implemented to ensure that at year-end, all grant revenues and expenses are double-checked to verify they are posted in the correct period. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO

View Audit 364026

Finding 573207 (2024-007)

None 2024

League for the Blind & Disabled, Inc.

IN

Questioned Costs Cash Management Internal Control / Segregation of Duties § 200.302 § 200.333 § 200.334

2024-007 Missing Supporting Documentation for Federal Reimbursement Claims Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. A process for retaining claims and supporting documentation has been implemented.

View Audit 364023 Questioned Costs: $1

Finding 573204 (2024-004)

Material Weakness 2024

League for the Blind & Disabled, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303

2024-004 Lack of Documented Approval Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has implemented various approval and documentation procedures.

View Audit 364023

Finding 573196 (2024-002)

Significant Deficiency 2024

City of Topeka, Kansas

KS

Questioned Costs Reporting Significant Deficiency § 200.303

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The re...

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The report will then be completed and submitted as the official report. The approval will be documented via email or other written confirmation. All approval records will be saved in the designated quarterly report file at or before the time of submission. If another staff member prepares or adjusts the report (e.g., due to leave), they will also document and save evidence of approval in the designated quarterly report file. Moving forward, the City will consistently retain documented approvals as part of the reporting process. Planned Completion Date: These modifications are being implemented immediately. Contact Person Responsible for Correction Action: Joshua McAnarney, Division Director of Finance & Budget or Designee

View Audit 364022

Finding 573172 (2024-001)

Significant Deficiency 2024

Academyhealth

DC

Questioned Costs Subrecipient Monitoring Reporting

Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently...

Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently negotiated and approved in March 2025. AcademyHealth is currently working with an outsourced auditor to prepare a proposal to obtain final rates through 2024. In the future, the Chief Financial Officer will submit the indirect cost rate proposal to obtain final rates for the fiscal year just completed, and requests for provisional rates for upcoming years will be submitted within the required timeframe.

View Audit 364004

Finding 573162 (2024-001)

None 2024

Kentucky Housing Corporation

TN

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.516

The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management wh...

The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.

View Audit 363980 Questioned Costs: $1

Finding 573161 (2024-001)

Significant Deficiency 2024

Clear Path for Veterans New England, Inc.

MA

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility ...

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility to ensure that participants are recertified within the allowable time frame. Anticipated Completion Date September 2025

View Audit 363979

Finding 573159 (2024-001)

Material Weakness 2024

New Jersey City University

NJ

Student Financial Aid Subrecipient Monitoring Cash Management

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.

View Audit 363978

Finding 573158 (2024-003)

Significant Deficiency 2024

Hawaiian Shores Community Association

HI

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit fi...

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Association will make the required transfers in fiscal year 2025 to ensure compliance with loan requirements. Name of the contact person responsible for corrective action: Jeff Sargent Planned completion date for corrective action plan: May 1, 2025

View Audit 363975

Finding 573124 (2024-001)

Significant Deficiency 2024

West Michigan Regional Medical Consortium

MI

Allowable Costs / Cost Principles Reporting Significant Deficiency

West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evan...

West MI Regional Medical Consortium respectfully submits the following corrective action plan for the year ended September 30, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave., Suite 1 Lansing, Michigan 48912 Audit Period: Year ended September 30, 2024 Organization Contact Person: Jerry Evans, MD; Medical Director The findings from the September 30, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding ‐ Federal audit Finding 2024‐001 ‐ Significant Deficiency Recommendation: West MI Regional Medical Consortium currently has procedures and controls in place to effectively monitor the status of the submission of the data collection form and the reporting package to ensure that the required information is submitted in a timely manner. The cause related to this finding was not due to failure in internal controls, therefore, we have no further recommendation for the Organization at this time. Action to be Taken: The Organization concurs with the facts of this finding and has procedures in place to ensure the timely submission of the data collection form and the reporting package.

View Audit 363935

Finding 573121 (2024-001)

Material Weakness 2024

The Addiction Center of Broome County, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal proces...

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal processes will be adjusted as needed. We will continue to monitor this area and document efforts to ensure ongoing alignment with applicable regulations. Contact Person Responsible for Corrective Action Plan: Lottie Albrecht, Director of Administration Phone Number: 607-940-0102 Email: lalbrecht@acbcservices.org Anticipated Completion Date of Corrective Action Plan: December 2025 (as part of preparation for fiscal year ending December 31, 2025)

View Audit 363928 Questioned Costs: $1

Finding 573115 (2024-002)

Material Weakness 2024

Genesee County Youth Corporation

MI

Eligibility Internal Control / Segregation of Duties Questioned Costs

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursemen...

2024 – 002 Lack of Segregation of Duties - Lack of Supervisory Review - Allow-ability of Expenses Charged to Grants The corrective action proposed for the above finding should be sufficient to account for any area of non-compliance in the evidence of supporting documentation for all disbursements. Additionally, the Business Operations Manager and Executive Director will implement a systematic review of all grant awards, contracts, and develop an addendum document charting all allowable expenses within each funding stream that will be utilized by the team when to determine proper allocation of disbursements. This chart will provide a quick guide to monitor compliance and allow-ability of expenditures to each funder at the time a check request is submitted. Checks

View Audit 363925 Questioned Costs: $1

Finding 573049 (2024-002)

Significant Deficiency 2024

Kewaunee County, Wisconsin

WI

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

Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to ...

Uniform Grant Guidance Implementation Recommendation: We recommend the County finalize the assessment of its financial management system and related internal controls over federal awards during the 2021 fiscal year. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new policies created, a plan to communicate these policies to County employees, and procedures to periodically review and update, as considered necessary. Action Planned/taken in response to the finding: Kewaunee County agrees with the finding. An assessment of all grants, requirements, and related policy and procedures is in progress and will continue to:  Evaluate existing policy and procedures for needed revisions  Document revisions to policy and procedures as necessary  Communicate any new policies to employees responsible for awards  Identify awards covered by the Uniform Guidance  Set and document a schedule for periodic review and revision Policy and procedures, as well as related documentation, are being revised as necessary to ensure compliance with the Uniform Guidance. Progress continues into 2024. The Finance Director will continue to coordinate and provide assistance and guidance to departments receiving grants subject to the Uniform Guidance. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh Planned completion date for corrective action: December 31, 2025

View Audit 363924

Finding 573043 (2024-003)

Significant Deficiency 2024

Kewaunee County, Wisconsin

WI

Questioned Costs Cash Management Reporting

Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing tra...

Review of Claim Forms and Expenditure Reconciliation Recommendation: We recommend that there is an appropriate reviewer of each grant claim and monthly reconciliation. Action planned/taken in response to the finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of claim forms and expenditure reconciliation. Names(s) of the contact person(s) responsible for corrective action: Paul Kunesh and Brian Johnson Planned completion date for corrective action: December 31, 2025

View Audit 363924

Finding 573040 (2024-002)

None 2024

The Chamber Foundation

ND

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.331

Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Addi...

Person responsible for corrective action: Nicole Meland, Vice President of Finance and Operations Responsible official’s response: Management is in agreement with this finding. Corrective action planned: The Chamber Foundation has subsequently requested all audit reports from all subrecipients. Additionally, the Chamber Foundation has changed subaward formatting to ensure that all required information is included within the award. Planned implementation date of corrective action: Ongoing

View Audit 363920

Finding 573036 (2024-001)

Material Weakness 2024

Banner Health

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025

View Audit 363912

Finding 573035 (2024-002)

Significant Deficiency 2024

Warren County, Missouri

MO

Questioned Costs Material Weakness Reporting § 200.303

The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.

View Audit 363908

Finding 573032 (2024-001)

Material Weakness 2024

Ncsc/usa Housing Development Corporation Two

FL

HUD Housing Programs Internal Control / Segregation of Duties Eligibility

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University D...

Oversight Agency for Audit, NCSC/USA Housing Development Corporation Two Operating as I.W. Abel Place, respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement stronger internal controls over the administration of tenant eligibility and file maintenance, inclusive of more rigorous staff training, to ensure HUD regulations are followed timely and accurately. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting, tenant file maintenance, and monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO Irene Phillips CFO

View Audit 363899

Finding 573029 (2024-009)

Material Weakness 2024

City of Nogales Arizona

AZ

Special Tests & Provisions Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.326

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: ...

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: There was no support provided for the three out of three contractor vendors with construction work noted on their purchase orders to support compliance with Davis Bacon. Corrective Action Plan: Regarding the wage tests for the Park’s grant, no information was provided to the City from the contractor of employee wages paid by the contractor. An email request and answer from the contractor was forwarded to the auditors, that the contractor was not responsible to report the wages. This in the future will be part of the Grants Coordinator position for Internal Control purposes, to ensure that any future construction contracts include the wage reporting requirements. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Finding 573028 (2024-008)

Material Weakness 2024

City of Nogales Arizona

AZ

Questioned Costs Material Weakness Reporting

2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local ...

2024 – 008 – Reporting Federal Agency: Department of the Treasury Department of Interior Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds (ARPA) Outdoor Recreation Acquisition, Development and Planning ALN: 21.027 15.916 Pass-Through Agency: Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning Arizona State Park Trails Pass-Through Number(s): Coronavirus State and Local Fiscal Recovery Funds (ARPA) N/A Outdoor Recreation Acquisition, Development and Planning 04-007-652304 Award Number and Period: Coronavirus State and Local Fiscal Recovery Funds (ARPA) 1505-0271 3/3/2021 – 12/31/2024 Outdoor Recreation Acquisition, Development and Planning 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: Coronavirus State and Local Fiscal Recovery Funds (SLFRF) (ARPA) - Audit procedures included testing the SLFRF Compliance Report. During the testing of the Compliance report, it was noted that the report’s key line items below were not properly supported: • Current period expenditure • Cumulative expenditure Current period expenditures per the Compliance Report was $-0- and per the expenditure details provided were $907,419 creating a difference of $907,419. Cumulative expenditures per the Compliance Report was $6,714,003 and per the expenditure details provided were $4,264,421 creating a difference of $2,449,582. Outdoor Recreation Acquisition, Development and Planning - Audit procedures included selection and testing of two quarterly reports. Two out of two of the quarterly reports tested contained no separate reviewer/approver support. FEDERAL AWARD FINDINGS (Continued) 2024 – 008 – Reporting (Continued) Corrective Action Plan: The City concurs with this finding. With the addition of the Grants Coordinator, all reporting of all departments will be filtered through this position. The City also will use an outside Grants consultant to help research, apply, and coordinate the City’s grants in entirety. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Corrective Action Plans

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