Corrective Action Plans

Finding 568028 (2024-004)

Significant Deficiency 2024

NY

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...

Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors

View Audit 360404

Finding 568024 (2024-002)

Significant Deficiency 2024

MacOn County Samaritan Memorial Hospital

MO

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

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...

FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .

View Audit 360393

Finding 568008 (2024-002)

Significant Deficiency 2024

Great Lakes Inter-Tribal Council Inc.

WI

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required re...

Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. This is a work in progress and will continue to be adjusted as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2025

View Audit 360368

Finding 567990 (2024-002)

Significant Deficiency 2024

Capital Area Development Corporation of West Virginia

WV

Reporting Internal Control / Segregation of Duties

Description of Finding: The audit team noted insufficient supervisory review and approval procedures related to the grant reporting function, specifically, a lack of documented supervisory review and approval prior to submission of grant reports which increases the risk of grant reporting errors or...

Description of Finding: The audit team noted insufficient supervisory review and approval procedures related to the grant reporting function, specifically, a lack of documented supervisory review and approval prior to submission of grant reports which increases the risk of grant reporting errors or omissions. As previously noted, 2024 was a year of transition with respect to executive leadership of the Charleston Area Alliance. Grant reporting previously handled at the executive level was delegated to experienced financial and program leaders within the organization who prepared grant reports collaboratively and reviewed reports prior to their submission. We acknowledge that approval of reports may not have been documented in writing other than in emails, and that reports were at times approved verbally prior to submission. Corrective Action: We will maintain written documentation of review and approval of future grant reports prior to submission. Contact Persons: Debra S. James, CPA, Chief Financial Officer 304-340-4253 djames@charlestonareaalliance.org Mara C. Boggs, Chief Executive Officer 304-340-4253 mboggs@charlestonareaalliance.org Anticipated Completion Date: July 1, 2025

View Audit 360333

Finding 567972 (2024-001)

Significant Deficiency 2024

Hughes Village Council

AK

Subrecipient Monitoring Reporting Significant Deficiency

Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting ...

Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Cynthia Beatus, IGAP Coordinator Corrective action plan: The IGAP Coordinator will ensure that the annual federal financial report (FFR) will be submitted within the 120 day timeframe of the end of the project period. Proposed Completion Date: September 30, 2025

View Audit 360316

Finding 567945 (2024-003)

Material Weakness 2024

Low Rent Housing Agency of Fort Madison

IA

Internal Control / Segregation of Duties Reporting

Another turnover in staff occurred in March 2025, since new staff has been in place, bank reconciliations have been done and properly recorded. The rent registers have been reconciled and “adjusted” to match tenant management software. Deposit breakdowns were not being reported correctly – all rec...

Another turnover in staff occurred in March 2025, since new staff has been in place, bank reconciliations have been done and properly recorded. The rent registers have been reconciled and “adjusted” to match tenant management software. Deposit breakdowns were not being reported correctly – all receipts except repayments and vending machine income was being recorded as dwelling rent. Extra utility charges and cable charges were not being recorded correctly. A new procedure has been put in place regarding rent receipts and payments are now being allocated correctly. Regarding payroll tax reports, we have changed payroll processing providers and are now receiving monthly reports and quarterly tax reports.

View Audit 360281

Finding 567931 (2024-002)

Material Weakness 2024

Hampton-Dumont Community School District

IA

Internal Control / Segregation of Duties

See Corrective Action Plan for chart/table

View Audit 360278

Finding 567921 (2024-015)

Significant Deficiency 2024

The City of Homewood, Alabama

AL

Reporting Significant Deficiency Internal Control / Segregation of Duties

The City does not concur. The City submitted their report to the Department of the Treasury on April 30, 2025 which covered the time period from January 1, 2022 through December 31, 2024. The Department of the Treasury allowed for this reporting deadline and the City maintains it filed the reports w...

The City does not concur. The City submitted their report to the Department of the Treasury on April 30, 2025 which covered the time period from January 1, 2022 through December 31, 2024. The Department of the Treasury allowed for this reporting deadline and the City maintains it filed the reports within the acceptable time requirements.

View Audit 360260

Finding 567920 (2024-014)

Significant Deficiency 2024

The City of Homewood, Alabama

AL

Reporting Internal Control / Segregation of Duties

The City does not concur. The City requested supporting documentation to verify department head approval was not obtained and it was not provided by the auditors. The City is unable to respond or correct a finding unless it has the details related to any audit issues.

View Audit 360260

Finding 567911 (2024-001)

Material Weakness 2024

City of Livonia, Michigan

MI

Cash Management Material Weakness Period of Performance § 200.303

Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditur...

Finding Number: 2024-001 Condition: The City lacked adequate controls to verify that expenditures charged to the grant were incurred within the proper period of performance. Transactions were processed without sufficient review or procedures around the period of performance, resulting in expenditures being charged from outside the allowable timeframe. Planned Corrective Action: The City has worked with the State to identify expenses outside the period of performance. The City has sent the money back to the State that was before the performance start date. All balances are properly stated as of November 30. 2024. Contact person responsible for corrective action: Connie Kumpula Anticipated Completion Date: 5/23/2025

View Audit 360257

Finding 567908 (2024-004)

Material Weakness 2024

Disability Rights South Dakota

SD

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

Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025

View Audit 360252

Finding 567893 (2024-005)

Significant Deficiency 2024

Hips

DC

Procurement, Suspension & Debarment Eligibility Reporting

Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has ...

Views of Responsible Officials: Prior to receiving this finding in the prior year, HIPS was not in the practice of saving documentation of financial or programmatic reporting submission. Staff responsible for submissions are now documenting submission of reports as of 2024. HIPS Finance Manager has been tasked with checking all spreadsheet calculations prior to submissions of financial reporting.

View Audit 360239

Finding 567892 (2024-004)

Significant Deficiency 2024

Hips

DC

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, emp...

Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, employees involved, % of time spent et al. In addition, the salaries and wages allocation is now a prerequisite for the invoicing process every month. HIPS have already seen significant improvements in both accuracy in seeking salaries and wages reimbursement as well as in wages reconciliations against paychex reports. COLA adjustments will be recorded more accurately and approval documented. As of 2024, HIPS has also updated our HR policy to provide written documentation by the Operations Manager of COLA increases to each staff member when they are implemented.

View Audit 360239

Finding 567886 (2024-002)

Material Weakness 2024

Housing Authority of the City of Hoboken

NJ

HUD Housing Programs Procurement, Suspension & Debarment Material Weakness

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Manager...

View of Responsible Officials and Corrective Actions: The following steps have been and are being taken regarding tenant certifications: 1. We issued a Request for Proposals for a third-party Contractor to perform all recertifications. We intend to award this Contract in July 2025. 2. All Managers and assistant Managers will use the third-party Contractor to learn proper recertification and documentation procedures.

View Audit 360230

Finding 567882 (2024-057)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Finding 2024-057 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The exception occurred due to an oversight during the transition to a new grant system. MSP immediately filed the report upon identifi...

Finding 2024-057 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - FFATA Reporting Management Views MSP agrees with the finding. The exception occurred due to an oversight during the transition to a new grant system. MSP immediately filed the report upon identification. Planned Corrective Action MSP will review and update procedures for additional monitoring of the FFATA reporting process. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Penny Burger, MSP

View Audit 360209

Finding 567848 (2024-052)

Material Weakness 2024

State of Michigan

MI

Subrecipient Monitoring Material Weakness Reporting § 200.514

Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to c...

Finding 2024-052 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - FFATA Reporting Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division updated its FFATA procedure effective March 2025 and has been working to correct the inaccurate FFATA reporting for the Refugee and Entrant Assistance State/Replacement Designee Administered Programs subawards. All of LEO’s open subawards are reported correctly in SAM and LEO completed corrections to the closed subawards in April 2025. Going forward, LEO will ensure that future subawards are reported both accurately and timely in accordance with FFATA requirements. Anticipated Completion Date Completed Responsible Individual(s) Heidi Parker, LEO

View Audit 360209

Finding 567835 (2024-044)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incomp...

Finding 2024-044 Temporary Assistance for Needy Families, ALN 93.558 - MiSACWIS Security Management and Access Controls Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., MDHHS currently has a process in place to review the user narrative describing the incompatible role exceptions within the DSA Michigan Statewide Automated Child Welfare Information System (MiSACWIS) request as part of the approval process. MDHHS will continue to work on adding an incompatible role form in the DSA MiSACWIS request with automated routing for appropriate approval. MDHHS anticipates completion of corrective action by October 30, 2025. For part b., MDHHS will evaluate the current DSA timelines for generation of access renewal and access drop requests and implement any necessary changes by September 30, 2025. MDHHS will continue to provide training for LOSCs via quarterly webinars to emphasize the appropriate procedures for granting access, reviewing, and comparing access. All new information related to security access is presented to the LOSCs during the webinars and one-on-one assistance is available as needed for additional support. Anticipated Completion Date a. October 30, 2025 b. September 30, 2025 Responsible Individual(s) Alana Lowe, MDHHS Deon Nelson, MDHHS

View Audit 360209

Finding 567755 (2024-007)

Significant Deficiency 2024

State of Michigan

MI

Eligibility Internal Control / Segregation of Duties

Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health A...

Finding 2024-007 CHAMPS Eligibility Interface Errors Management Views MDHHS agrees with the finding. Planned Corrective Action Bridges is the system of record for eligibility and produces reports with potential duplicate records for local office staff to review. In addition, the Community Health Automated Medicaid Processing System (CHAMPS) is currently designed to reject potential duplicate records to prevent duplicate payments for the same individuals that already exist in CHAMPS and places these records on a CHAMPS report for review. These two reports could potentially contain the same duplicate records identified by both CHAMPS and Bridges. As part of the Departmental Work Intake Process for prioritization, MDHHS submitted a work request during January 2023 for a Bridges system modification that would allow data from the Bridges reports to be exported to the Bridges data warehouse and MDHHS is currently working with DTMB to obtain access to the data. MDHHS central office will develop a process to reconcile the rejected records identified on the CHAMPS and Bridges reports and ensure that MDHHS is appropriately reviewing those records and making any necessary corrections. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS

View Audit 360209

Finding 567706 (2024-030)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.302

Finding 2024-030 Rehabilitation Services Vocational Rehabilitation Grants to States, ALN 84.126 - Accuracy of Financial Reports Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Improvements to documented procedures f...

Finding 2024-030 Rehabilitation Services Vocational Rehabilitation Grants to States, ALN 84.126 - Accuracy of Financial Reports Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Improvements to documented procedures for the Vocational Rehabilitation Financial Report (RSA-17) preparation to ensure consistency and accuracy of financial report submissions. 2. Specific RSA-17 training for applicable staff and management in order to enhance knowledge of reporting requirements. 3. An additional layer of management review on RSA-17 financial reports prior to submission. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Heidi Parker, LEO Chris Johnson, LEO

View Audit 360209

Finding 567698 (2024-027)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.332

Finding 2024-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Subaward Information Management Views MDOT and LEO agree with parts a. and b. of the finding, respectively. For part c., the Michigan Strategic Fund (MSF) agrees that the subaward agreements did not specify whether th...

Finding 2024-027 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Subaward Information Management Views MDOT and LEO agree with parts a. and b. of the finding, respectively. For part c., the Michigan Strategic Fund (MSF) agrees that the subaward agreements did not specify whether the award was for research and development (R&D) purposes. The omission occurred because MSF does not administer awards intended to support R&D activities under this program; accordingly, this designation was not included in the grant agreement. MSF also agrees that the subaward agreements did not include an indirect cost rate. MSF did not fund indirect costs as part of this program; therefore, an indirect cost rate was not included in the grant agreement. Planned Corrective Action For part a., MDOT will incorporate into its current process all required subaward information to ensure it is reported to subrecipients, which will include, but not be limited to, UEI, Federal Award Identification Number (FAIN), federal award date, subaward period of performance start and end date, subaward budget period start and end date, federal awarding agency name, assistance listing number (ALN) title, identification of whether the award is for R&D, indirect cost rate for the federal award, an approved federally recognized indirect cost rate for the subrecipient, and the closeout terms and conditions. MDOT will also provide current subrecipients with the missing required subaward information. For part b., the LEO Prosperity Division will review records to identify all subrecipients that were previously provided with incorrect FAINs and will provide them with correct information. In addition, the LEO Prosperity Division will implement a procedural change to have a reviewer check to ensure that award information is accurately stated before grant issuance. For part c., to align with Uniform Guidance requirements (2 CFR 200.332(a)) all future agreements under the program will explicitly state that: 1) funding is not intended to support R&D activities; and 2) indirect costs are not eligible costs. All applicable current subrecipients will be notified of the same. Anticipated Completion Date a. September 30, 2025 b. July 31, 2025 c. July 31, 2025 Responsible Individual(s) a. Gina Huhn, MDOT Jean Ruestman, MDOT b. Denise Flannery, LEO c. Jay Williams, MSF Amy Rencher, MSF Gregory West, MSF Christine Whitz, MSF Christina Degrow, MSF

View Audit 360209

Finding 567697 (2024-026)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303

Finding 2024-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB implemented process improvements in May 2024 related to the tracking and documentation of...

Finding 2024-026 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Workfront Security Management and Access Controls Management Views DTMB agrees with the finding. Planned Corrective Action DTMB implemented process improvements in May 2024 related to the tracking and documentation of user access requests to support approval of user access and system roles. The exceptions cited are related to users whose access was granted prior to the improved documentation being implemented. Anticipated Completion Date Completed Responsible Individual(s) Jennifer Edmonds, DTMB

View Audit 360209

Finding 567694 (2024-023)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure ...

Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure that Public Transportation Management System (PTMS) user access is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process which will include obtaining, verifying, and documenting the written approval for all identified users by the designated System Security Administrators. Access will be modified/removed, as appropriate, based on responses or removed for non-responders prior to the end of each six-month period for privileged users and each fiscal year for all other users. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Sandy Lovell, MDOT Gina Huhn, MDOT Jean Ruestman, MDOT Kyle Nelson, MDOT Andy Esch, MDOT

View Audit 360209

Finding 567691 (2024-001)

Significant Deficiency 2024

State of Michigan

MI

Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2024-001 SIGMA High-Risk Activity Monitoring Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Updated procedures that ensure completeness of high-risk activity reports by adjusting date parameters of weekly ...

Finding 2024-001 SIGMA High-Risk Activity Monitoring Management Views LEO agrees with the finding. Planned Corrective Action The LEO Finance Division will implement the following: 1. Updated procedures that ensure completeness of high-risk activity reports by adjusting date parameters of weekly reports. 2. A layer of review by management that oversees SIGMA override processes and transactions to ensure appropriateness. 3. A procedure to ensure the adequate retention of management review documents. Anticipated Completion Date August 31, 2025 Responsible Individual(s) Robert Mason, LEO Mary McGrath, LEO

View Audit 360209

Finding 567678 (2024-021)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties Subrecipient Monitoring Period of Performance § 200.303 § 200.308

Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers...

Finding 2024-021 National Guard Military Operations and Maintenance (O&M) Projects, ALN 12.401 - Extension Procedures Management Views DMVA agrees with the finding. Planned Corrective Action DMVA will set annual recurring calendar appointments to review program activities with the program managers one month before the end of the period of performance to ensure a joint understanding of extension requirements, allowing sufficient time to prepare and submit period of performance extension requests timely, if needed. Anticipated Completion Date September 1, 2025 Responsible Individual(s) Rachelle Breeden, DMVA

View Audit 360209

Finding 567676 (2024-010)

Significant Deficiency 2024

State of Michigan

MI

Internal Control / Segregation of Duties § 200.303

Finding 2024-010 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action For MiND, the standard change management process requires documenting the test results. However, there are scenarios when the data in question is only in the production environme...

Finding 2024-010 MDE, Change Management Process Management Views MDE agrees with the finding. Planned Corrective Action For MiND, the standard change management process requires documenting the test results. However, there are scenarios when the data in question is only in the production environment; or it might be production specific deployment like changing application settings which does not have relevance to the test environment. In these cases, MDE will maintain documentation in DevOps that the deployment is production specific. MDE will increase the post-review process of MiND related work items from a semi-annual to quarterly basis to ensure all required evidence of testing is recorded appropriately. For NexSys, MDE will review the change management process with DTMB and implement additional steps to ensure tickets are closed in a timely manner and all testing results have been appropriately documented. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Monica Butler, MDE Peter Jones, MDE

View Audit 360209

Corrective Action Plans

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