Corrective Action Plans

Finding 574606 (2024-003)

Material Weakness 2024

Jefferson County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...

FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.

View Audit 364861

Finding 574604 (2024-002)

None 2024

Village of Harwood Heights

IL

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late...

FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late in the case of the 2024 grant. Plan: Management will monitor grant expenditure reports closely and will improve their control activities to ensure that grant performance reports are filed as required by the grant agreement. Anticipated Date of Completion: As soon as possible – before FY26 year end Name of Contact Person: Mary Ventrella, CPA - Finance Director Management Response: Since the audit, we have evaluated our monitoring procedures and control activities to ensure that grant expenditure reports are readily available and grant performance reports are filed timely.

View Audit 364860

Finding 574590 (2024-002)

Significant Deficiency 2024

Minnesota Prairie County Alliance

MN

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...

Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.

View Audit 364815

Finding 574589 (2024-001)

Significant Deficiency 2024

Minnesota Prairie County Alliance

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...

Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.

View Audit 364815

Finding 574464 (2024-002)

Significant Deficiency 2024

Municipality of Gurabo

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512

We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.

View Audit 364800

Finding 574463 (2024-004)

Material Weakness 2024

Winner Regional Healthcare Center

SD

Special Tests & Provisions Subrecipient Monitoring Material Weakness

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025

View Audit 364799

Finding 574462 (2024-001)

None 2024

Adjoin

CA

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302

June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...

June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin

View Audit 364796 Questioned Costs: $1

Finding 574451 (2024-001)

None 2024

Indiana University Health, Inc. and Subsidiaries

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...

Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A

View Audit 364785

Finding 574443 (2024-001)

Significant Deficiency 2024

Shawano County Housing Authority

WI

Internal Control / Segregation of Duties

The Authority is aware of the lack of segregation of duties caused by the limited size of its staff. Segregation of duties is enhanced whenever possible and the Board of Comissioners assumes an active roll through monthly review of receipt and disbursement transactions and monthly financial stateme...

The Authority is aware of the lack of segregation of duties caused by the limited size of its staff. Segregation of duties is enhanced whenever possible and the Board of Comissioners assumes an active roll through monthly review of receipt and disbursement transactions and monthly financial statements.

View Audit 364779

Finding 574438 (2024-002)

Material Weakness 2024

Central Columbia School District

PA

Cash Management Reporting School Nutrition Programs

Contact Person: Steven Dolak, Business Administrator. Recommendation: The District should revise procedures to ensure the data entered into the claim for reimbursement is reviewed for accuracy prior to the report being submitted. Evidence of the approval of submission should be documented in writi...

Contact Person: Steven Dolak, Business Administrator. Recommendation: The District should revise procedures to ensure the data entered into the claim for reimbursement is reviewed for accuracy prior to the report being submitted. Evidence of the approval of submission should be documented in writing, such as with an initial, to demonstrate the review of the information has been performed. Action: The Business Administrator will prepare the reports for submission. Prior to submitting the report through the reimbursement system, a second individual will review the information entered. Upon satisfactory completion of the review, the second individual will acknowledge review by initialing and dating the document(s). Date of Completion: This procedure will be implemented at the beginnign of the 2025-26 school year.

View Audit 364777

Finding 574408 (2024-001)

Material Weakness 2024

Family & Childcare Resources of Northeast Wisconsin, Inc.

WI

Internal Control / Segregation of Duties

This finding will not be completely resolved given the limited amount of financial staff and limited financial resources of the Organization. The Organization will rely on Board oversight and review of the financial records.

View Audit 364769

Finding 574383 (2024-002)

Significant Deficiency 2024

Childcaring, Inc.

WI

Internal Control / Segregation of Duties

This finding will not completely resolve itself given the cost/benefits basis the Organization continues to base this decision on.

View Audit 364767

Finding 574183 (2024-001)

Significant Deficiency 2024

Wisconsin Rural Water Association, Inc.

WI

Internal Control / Segregation of Duties

The Organization is aware of the lack of segregation of duties caused by the limited size of its staff, and will continue to use other controls, where practical to compensate for this limitation.

View Audit 364760

Finding 574175 (2024-001)

Significant Deficiency 2024

East Texas Crisis Center, Inc.

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Procurement, Suspension & Debarment § 200.112 § 200.303 § 200.331 § 200.333 § 200.338

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allow...

Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.

View Audit 364753

Finding 574174 (2024-001)

Significant Deficiency 2024

College of the Ozarks

MO

Reporting Internal Control / Segregation of Duties § 200.303 § 200.502 § 200.510

Views of responsible personnel and planned corrective actions: Management concurs with this finding. The College has implemented immediate corrective actions including development of a comprehensive grant tracking spreadsheet and establishment of regular meetings between program and finance staff. A...

Views of responsible personnel and planned corrective actions: Management concurs with this finding. The College has implemented immediate corrective actions including development of a comprehensive grant tracking spreadsheet and establishment of regular meetings between program and finance staff. Additionally, effective immediately, all grant applications must be reviewed and approved by the Controller prior to submission to ensure proper identification of funding sources and compliance requirements. The College will also implement cutoff procedures to ensure federal expenditures are reported in the correct period based on when eligible costs are incurred. The Controller will review all G5 drawdowns near year-end to verify proper period reporting. Formal written procedures for SEFA preparation will be implemented by October 15, 2025. The Controller will maintain the master grant listing and review all grant agreements to determine federal funding sources. Beginning with fiscal year 2026 SEFA preparation, the CFO will perform an independent review for completeness and accuracy, including verification of proper period reporting for all federal expenditures.

View Audit 364751

Finding 574172 (2024-001)

Significant Deficiency 2024

Barron County Housing Authority

WI

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit...

Rent Reasonableness Calculations Corrective Action Plan (CAP): Recommendation: We recommend, the entity develop a process to verify that rent reasonableness calculations are completed and maintained in the files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Authority will train individuals doing the calculations to ensure calculations are done and maintained in the files and implement processes to verify rent reasonableness calculations are done. Name of the contact person responsible for corrective action: Bob Kazmierski Planned completion date for corrective action plan: December 31, 2024

View Audit 364743

Finding 574147 (2024-005)

Significant Deficiency 2024

New Mexico Rural Water Association

NM

Internal Control / Segregation of Duties

It is management’s policy that all disbursements are documented and receipts and invoices retained. In an effort to ensure that receipts do not get misplaced or misfiled, management will look at employing scanning technology to make this process more secure.

View Audit 364720

Finding 574146 (2024-004)

Significant Deficiency 2024

New Mexico Rural Water Association

NM

Cash Management Internal Control / Segregation of Duties

It is management’s policy to update and distribute travel reimbursement forms with new mileage and per diem rates at the beginning of each year, and any other time the rates may change. Travel and per diem rates are reviewed periodically to ensure current rates are used. A staff person was utilized ...

It is management’s policy to update and distribute travel reimbursement forms with new mileage and per diem rates at the beginning of each year, and any other time the rates may change. Travel and per diem rates are reviewed periodically to ensure current rates are used. A staff person was utilized for a period of time over the past year, but that process was not continued through the full year. Utilization of a staff person to review vouchers prior to payment will begin again, and will be used continuously in the future.

View Audit 364720

Finding 574145 (2024-002)

Significant Deficiency 2024

Connected Lane County

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.212 § 200.512

Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in ...

Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in paper files in the finance department for easy access during the course of the audit. Person(s) Responsible: Mary Bell, Finance Manager Anticipated Completion Date: September 1, 2025

View Audit 364714

Finding 574144 (2024-004)

Significant Deficiency 2024

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328 § 200.329

Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.

View Audit 364712

Finding 574140 (2024-002)

Significant Deficiency 2024

Town of Babylon

NY

Reporting Internal Control / Segregation of Duties § 200.328

The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mi...

The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mitigate the reporting lapse since the oversight. To prevent recurrence, the Town has implemented the following corrective actions: 1. Formal Reporting Calendar: A centralized ARPA reporting calendar has been created. This calendar will include internal deadlines at least 14 days in advance of federally mandated submission dates. 2. Assigned Reporting Officer: A designated ARPA Reporting Officer has been appointed, responsible for coordinating all necessary documentation and submissions related to ARPA funding. 3. Pre-Submission Review Process: A new protocol has been established requiring internal review and sign-off from both the Comptroller and the Town Supervisor’s designee no less than one week prior to each deadline. 4. Ongoing Training and Coordination: The Town will continue to work closely with its auditors and legal counsel to remain current on federal guidance, ensure continued compliance with Uniform Guidance standards, and maintain internal staff awareness of applicable obligations under ARPA. We believe these measures will ensure timely and accurate reporting for all future quarters and strengthen our internal compliance infrastructure.

View Audit 364708

Finding 574131 (2024-004)

Material Weakness 2024

Legacy Medical Care Inc.

IL

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

View Audit 364705

Finding 574129 (2024-002)

Material Weakness 2024

Legacy Medical Care Inc.

IL

Material Weakness Internal Control / Segregation of Duties

Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible fo...

Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 08/15/2025

View Audit 364705

Finding 574121 (2024-001)

Material Weakness 2024

Wessington Springs School District No. 36-2

SD

Internal Control / Segregation of Duties Material Weakness

For this finding, Dr. Michael Ormsmith is the contact person responsible for the corrective action plan. This finding is due to having only two employees in the Business Office, both who have separate duties to cover the workload. Staffing in the office is at an efficient and financially feasible ...

For this finding, Dr. Michael Ormsmith is the contact person responsible for the corrective action plan. This finding is due to having only two employees in the Business Office, both who have separate duties to cover the workload. Staffing in the office is at an efficient and financially feasible level and precludes the hiring of additional personnel to provide an ideal environment for internal controls. The Wessinton Springs School Districted adopted Policy DA-R(1) Fiscal Management Internal Controls and Procedures on January 9, 2023. The district is aware of the weakness in internal controls and will adhere to the policy we have in place while providing compensating controls to reduce the risk. This is an ongoing process.

View Audit 364703

Finding 574119 (2024-001)

Significant Deficiency 2024

Brockton Housing Authority

MA

Questioned Costs HUD Housing Programs Eligibility

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing

View Audit 364699 Questioned Costs: $1

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