Corrective Action Plans

Finding 1159891 (2023-004)

Material Weakness 2023

Jefferson Parish

LA

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties

With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, proc...

With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, procedures, and internal controls with the goal of improving audit readiness, refine documentation procedures, and strengthen internal controls to support accurate and complete financial data going forward. As part of this effort Jefferson Parish and Deloitte are working across Departments to re-define organizational structure, to establish governance and oversight between finance, accounting, and programmatic departments. Jefferson Parish and Deloitte are also working to implement data quality improvement measures, including the establishment of quarterly grants reconciliation and review processes. Jefferson Parish has also engaged Infor in the implementation of new financial and reporting technology to support improved financial processing and controls. Chief Administrative Assistant Nichole Thompson will develop process to monitor the submission of timely reports in compliance with federal requirements. This process should be enacted by January of 2026.

View Audit 370431

Finding 1159890 (2023-002)

Material Weakness 2023

City of Williamsport

PA

Reporting Internal Control / Segregation of Duties

The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected as of December 2024.

View Audit 370430

Finding 1159792 (2023-006)

Material Weakness 2023

Program of Academic Exchange

NY

Questioned Costs Subrecipient Monitoring Internal Control / Segregation of Duties

Based upon current auditor’s recommendation, PAX established an effort verification reporting system. This system was launched in FY23 and enhanced in FY24 with great specificity and fuller allocation information. The latest system will accurately capture the effort spent by each employee on specifi...

Based upon current auditor’s recommendation, PAX established an effort verification reporting system. This system was launched in FY23 and enhanced in FY24 with great specificity and fuller allocation information. The latest system will accurately capture the effort spent by each employee on specific grants, ensuring proper documentation of allocation of wages and salaries to the respective federal awards.

View Audit 370335 Questioned Costs: $1

Finding 1159718 (2023-002)

Material Weakness 2023

Prescott School District No. 402-37

WA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.

View Audit 370309 Questioned Costs: $1

Finding 1159681 (2023-004)

Material Weakness 2023

Adelante Community Development

CO

Reporting Significant Deficiency Internal Control / Segregation of Duties

We will get physical signatures on submitted timesheets.

View Audit 370269

Finding 1159562 (2023-007)

Material Weakness 2023

County of Montgomery

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259,...

2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259, 17.277, 17.278, 17.283, 20.205, 21.023, 21.027, 93.558, 93.959, 93.778, 97.036 Federal Award Identification Number and Year: Various Pass-Through Agency: Various Pass-Through Number(s): Various Award Period: 1/1/2023 – 12/31/23 Type of Finding: Other Matters and Significant Deficiency in Internal Control Over Compliance Condition: The County’s single audit and reporting package was delayed for the year ended December 31, 2023, beyond the due date. Recommendation: The County should evaluate its procedures around timely submission of the single audit. 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 recurrence of the finding is in part a result of the timing of when the finding was issued. The 2023 ACFR was issued on February 14, 2025. The Single Audit began after that in late February 2025. At that point the 2023 Single Audit was already past the submission deadline. The County prioritized completion of the 2023 Single Audit and has allocated staff time from the Controller’s department and hired outside temporary professional staffing to complete the audit. Throughout the process, the Grant Accountant and Controller staff have facilitated communication and information between grant-funded departments and CLA resulting in a quick turnaround and completion of the Single Audit. Continued use of Infor’s grant management system and Project codes are increasing efficiency in accurately completing the SEFA and providing documentation as requested for programs being audited. The County began implementing a grant accounting system as part of our implementation of Infor in mid-2021 and are continuing to work with departments to refine their use of the systems. The County is working to compile information required for the 2024 ACFR, and the 2024 SEFA preparation is underway. To expedite this process, the County has engaged additional contract professional staff and is also in the process of hiring an additional full-time employee in the Grant Accounting area. Depending on external auditor availability and other Financial Audits being conducted, the 2024 SEFA will be complete and ready for review by August 2025, with a goal of timely completion of the 2024 Single Audit by the due date of September 30, 2025. 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 370214

Finding 1158234 (2023-001)

Material Weakness 2023

Grady Memorial Hospital Corporation

GA

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

To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...

To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained

View Audit 370125

Finding 1156583 (2023-003)

Material Weakness 2023

City of Logansport

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 cler...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: As a measure of corrective action, I will be implementing a check sheet that will be attached to every claim sheet. This new procedure requires that you go through the check sheet and initial each item to ensure that all procedures have been followed correctly before submission. Additionally, I will also maintain a check sheet in my office since I am the last person to review each claim. This will help to ensure thoroughness and accuracy in our claims processing. Furthermore, moving forward, any grant funds will be placed into their own individual funds and distributed through an individual account. This approach will allow us to track payments for any expenses associated with these funds more effectively. Additionally, the BOT expenditure is done and in the future we will do a better job. Anticipated Completion Date: October 31,2025

View Audit 368938 Questioned Costs: $1

Finding 1156443 (2023-001)

Material Weakness 2023

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

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

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore...

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2024 and 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following additional items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Deadlines (monthly, quarterly, etc.) o Proof of submission

View Audit 368718

Finding 1156031 (2023-010)

Material Weakness 2023

City of Stamford, Connecticut

CT

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous ...

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous documentation of payroll and invoices tied to FEMA projects. Grants Officer to oversee federal disaster recovery funds. Timeline: New procedures adopted October 2025; effective for any new FEMA claims. Responsible Party: Grants Officer in coordination with relevant departments

View Audit 368535 Questioned Costs: $1

Finding 1155970 (2023-005)

Material Weakness 2023

Incline Village General Improvement District

NV

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.512

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the f...

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the fiscal year-end. Condition The District’s reporting package for the fiscal year ended June 30, 2023, was not submitted to the Federal Audit Clearinghouse within the required timeframe. As of the date of this report, the reporting package has not yet been submitted. Cause The District did not have adequate procedures in place to ensure timely completion of the financial audit and preparation of the reporting package. Effect The District did not comply with the Uniform Guidance submission deadline, which may impact the timeliness of federal oversight and potentially affect future federal funding decisions. Questioned Costs No questioned costs were identified as a result of our procedures. Context/Sampling The FY2023 Single audit was performed in 2025 after it was determined that the grant funds were expended on eligible activities, triggering the Single Audit requirement. The delay was due to the District not identifying the requirement timely and lacking procedures to ensure prompt submission. Recommendation We recommend that the District implement processes and internal controls to ensure future Single Audits are completed and submitted within the required timeframe. Management’s Corrective Action Planned Management concurs with the recommendation. IVGID will establish a procedure to review and reconcile grants both federal and state at year-end to determine the need for a single audit and submission to the required agencies.

View Audit 368379

Finding 1155827 (2023-006)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155826 (2023-005)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving depos...

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving deposit requirement suspended permanently. If management is successful in negotiations with HUD, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155825 (2023-004)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155824 (2023-003)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155631 (2023-001)

Material Weakness 2023

Philadelphia Area Labor Management Committee

PA

Reporting Internal Control / Segregation of Duties § 200.512

U.S. Department of Commerce, Philadelphia Works, Inc. 2023-1 Timely submission of Data Collection Form – Assistance Listing Number 11.307 Recommendation: We recommend PALM engage a certified public accountant to conduct a Single Audit as long as the PALM meets the Single Audit criteria Explanation o...

U.S. Department of Commerce, Philadelphia Works, Inc. 2023-1 Timely submission of Data Collection Form – Assistance Listing Number 11.307 Recommendation: We recommend PALM engage a certified public accountant to conduct a Single Audit as long as the PALM meets the Single Audit criteria Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has engaged a certified public accountant to complete a Single Audit and assist in the submission of the data collection form. Name of contact person responsible for corrective action: Anthony Wigglesworth, Executive Director. Corrective action plan has been implemented prior to the due date of the December 31, 2024 data collection form.

View Audit 367886

Finding 1155487 (2023-003)

Material Weakness 2023

Oak Hill United School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not lim...

FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Treasurer. Due to the lack of effective internal controls one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER III, Year 2 report, which covered the period of July 1, 2021 to June 30, 2022, total expenses per the report were $688,778. However, the School Corporation’s ledger had total expenses for the award, for that time period, of $784,638. The lack of controls and noncompliance were isolated to the ESSER III, Year 2 report. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As the finding and error occurred in one entry of one report the district will continue the practice of having a second party review financial system data against report entries. The error in this instance was a misunderstanding of the entry. A secondary review of reporting guidelines and entries will take place prior to submission of any ESSER Data Reporting. Anticipated Completion Date: Upon the next submission of ESSER Data reporting.

View Audit 367782

Finding 1155459 (2023-003)

Material Weakness 2023

Claremont Learning Partnership

NH

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.313 § 200.317 § 200.431

Finding 2023-003: Establish and maintain effective internal control over the Federal award Plan: We have ensured all policies and procedures have been vetted by an attorney and approved by the River View Board of Trustees and the Claremont Learning Partnership Board of Directors. Moving forward, the...

Finding 2023-003: Establish and maintain effective internal control over the Federal award Plan: We have ensured all policies and procedures have been vetted by an attorney and approved by the River View Board of Trustees and the Claremont Learning Partnership Board of Directors. Moving forward, the Executive Director will ensure that all policies and procedures stay current and are reviewed by the Board annually. FY-22 & FY-23 Audits were completed in tandem, all corrections were made as soon as the issue was identified. Expected Implementation Date: RiverView amended the policy on June 17, 2025, CLP amended the policy on July 3, 2025. Contact: Cathy Pellerin Executive Director, Claremont Learning Partnership 169 Main Street; Claremont, NH 03743 603-287-7120

View Audit 367741

Finding 1155375 (2023-004)

Material Weakness 2023

Vigo County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance progra...

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on all of the 3 vendors determined to have covered transactions, totaling $141,131, that were paid with SLFRF funds. Contact Person Responsible for Corrective Action: Larry Hutchings Larry.hutchings@vigocounty.in.gov 812-462-3361 Views of Responsible Officials: We concur with the findings Description of The Corrective Action Plan: The Auditors Office has created a Policy for Suspension and Debarment within the Subrecipient Ploicy. A clause or condition must also be included in the covered transaction with that entity to require reporting of any debarment or suspension occurring during the subgrant period; and, Maintain documentation to support the verification was done before or at the time of contract execution. Anticipated Completion Date – 08/13/2025

View Audit 367621

Finding 1155309 (2023-015)

Material Weakness 2023

The City of Frederick, Maryland

MD

Questioned Costs Subrecipient Monitoring Eligibility

All expenditures will be verified prior to disbursement to ensure they are paid within the defined grant period.

View Audit 367551 Questioned Costs: $1

Finding 1155308 (2023-014)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Eligibility Reporting

The Maryland Departments of Human Services (DHS) and Housing and Community Development (DHCD) are the direct recipient of the federal funds for OHEP and WAP, respectively. Because of this, all verification occurs on the state level and HHS does not have access to all pertinent information. As the re...

The Maryland Departments of Human Services (DHS) and Housing and Community Development (DHCD) are the direct recipient of the federal funds for OHEP and WAP, respectively. Because of this, all verification occurs on the state level and HHS does not have access to all pertinent information. As the recipient of these funds, HHS is informed by DHS or DHCD when a Crisis Client is to be served by HHS. HHS is not responsible for the verification of Crisis Client eligibility for either program.

View Audit 367551

Finding 1155307 (2023-013)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Reporting Significant Deficiency

SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicate...

SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicated by the need for controls in place to ensure the final numbers are correct.

View Audit 367551

Finding 1155299 (2023-005)

Material Weakness 2023

The City of Frederick, Maryland

MD

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles

Client intakes are now being updated within the fiscal year, ensuring that client information is accurate and timely. Additionally, the Department's new EHR will prompt providers to update proof of income on an annual basis.

View Audit 367551

Finding 1155297 (2023-003)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting Internal Control / Segregation of Duties

The finance department will review Form SF-425 compared to financial reports prior to submittals. Quarterly reminders have been initiated to ensure timely reporting moving forward.

View Audit 367551

Finding 1155295 (2023-008)

Material Weakness 2023

West Side Community Health Services INC

MN

Reporting Internal Control / Segregation of Duties § 200.303

2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/a...

2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025

View Audit 367533

Corrective Action Plans

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