Corrective Action Plans

Finding 1156569 (2024-003)

Material Weakness 2024

NJ

HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking

U.S. Department of Housing and Urban Development 2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – PIC Submissions Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explan...

U.S. Department of Housing and Urban Development 2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – PIC Submissions Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will increase oversight in the Section 8 Housing Choice Voucher program to ensure that established internal control policies are being followed. HUD-50058s are transmitted monthly. Some transmissions have PIC errors while other files that are submitted late due to annual recertification completion. The Authority has plans in place to ensure quality control and resubmission of any errors and to improve timely annual completion and submission. Name(s) of the contact person(s) responsible for corrective action: Philisa Smith, HCV Director Planned completion date for corrective action plan: December 31, 2026

View Audit 368905

Finding 1156551 (2024-004)

Material Weakness 2024

Andrew County Health Department

MO

Cash Management Reporting Significant Deficiency

Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and perf...

Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and performance reports.

View Audit 368888

Finding 1156543 (2024-002)

Material Weakness 2024

Samaritas and Subsidiaries

MI

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

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025

View Audit 368884 Questioned Costs: $1

Finding 1156525 (2024-001)

Material Weakness 2024

Sustainable Fisheries Partnership Foundation

HI

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025

View Audit 368873

Finding 1156486 (2024-001)

Material Weakness 2024

The George E. Brown United States-Mexico Foundation for Science

DC

Matching / Level of Effort / Earmarking

The Foundation pursued legal action because the way in which the IMPI withdrew from our agreement was found to be illegal. The Mexican court agreed with our position, and by the end of 2021, the Foundation had received a favorable resolution on the 2020 lawsuit. This led to initial meetings with IMP...

The Foundation pursued legal action because the way in which the IMPI withdrew from our agreement was found to be illegal. The Mexican court agreed with our position, and by the end of 2021, the Foundation had received a favorable resolution on the 2020 lawsuit. This led to initial meetings with IMPI's renewed top management, but unfortunately, we were unable to reset the funds. In June 2022, the Foundation formally requested that the IMPI reset the funds in order to continue functioning under the agreement, as a legally developed addendum had been created to supplement the original agreement. There were hectic changes in top management at the Mexican Ministry of Economy and the IMPI in 2022, resulting in unproductive efforts from previous negotiations. Then, in July 2023, the Foundation submitted a second lawsuit to enforce the one won in 2021, which was accepted by the court. On 13 September 2024, the Foundation was notified by the court of a favorable resolution regarding this second lawsuit. The IMPI still has one final opportunity to contest this resolution, although the probability of changing the outcome is minimal. Consequently, the Foundation's executives and its Board of Governors resumed communication with the IMPI's legal team to accelerate the resetting of the funds and the collaboration agreement. This was unsuccessful. Although the final ruling generally favored the Foundation, FUMEC filed a direct appeal for constitutional protection, claiming that the returns generated should not be limited to December 2022 but should instead be accumulated and calculated until IMPI actually made the payment; that is, until the month of 2024 in which IMPI complied with the ruling handed down on July 1, 2024. The court revoked the contested trial of July 1, 2024, and issued a new ruling, reiterating the considerations regarding the period and the amounts that IMPI is obliged to pay to FUMEC, in order to fully restore FUMEC's infringed subjective right. In compliance with this ruling, on September 8, 2025, the court issued a new ruling considering that the Collaboration Agreement was still in force and that IMPI had not demonstrated that it had fulfilled its obligations. Consequently, and reiterating its previous ruling, the court granted IMPI a period of no more than four months to comply with the Collaboration Agreement. IMPI was therefore required to reimburse the principal funds of $5 million USD to FUMEC’s endowment and pay the returns due for the period from August 2020 to May 2024. Proposed completion date – 2Q2026. Contact person – Eugenio Marin, Executive Director

View Audit 368844

Finding 1156477 (2024-002)

Material Weakness 2024

Lifewire

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.430

Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...

Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.

View Audit 368819

Finding 1156471 (2024-001)

Material Weakness 2024

Emergency Food Network of Tacoma and Pierce County

WA

Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.430

U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee sp...

U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.

View Audit 368815 Questioned Costs: $1

Finding 1156466 (2024-001)

Material Weakness 2024

Council Towers Housing Development Fund Corporation

NY

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.

View Audit 368800 Questioned Costs: $1

Finding 1156454 (2024-002)

Material Weakness 2024

Connections to Success

MO

Cash Management Reporting Significant Deficiency § 200.303

Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create...

Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create an internal control for drawdown request and report approval and review. The Organization should ensure these policies are followed for all drawdowns, reports and that documentation related to these policies are maintained. Views of Responsible Officials: Management agrees with the finding and recommendation. To address this, the Organization will update its Cash Management Policy to implement a documented, two-level review and approval process for all drawdown requests and reports, requiring both preparer and approver sign-off and develop a standard checklist to ensure each drawdown is supported by allowable, documented expenditures prior to submission. The Grants Manager will conduct quarterly internal reviews to ensure this process is being followed. Contact information for this finding: If the U.S. Department of Labor has questions regarding this schedule, please call Brandi Janke at (816) 520-4404. Completion Date: September 2025

View Audit 368768

Finding 1156346 (2024-004)

Material Weakness 2024

City of Seattle

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) M...

The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. The contract specialist receives structured management oversight and ongoing training to strengthen capacity for accurate budget monitoring. In July 2025, the FGMU updated its ESG policies and procedures to incorporate improved controls for earmarking. In addition, the Department has instituted regular training sessions for all staff responsible for federal grant management to reinforce compliance with earmarking and other federal requirements. These corrective actions are designed to strengthen internal controls, provide clearer oversight, and ensure that future expenditures remain within established budget and earmarking limits.

View Audit 368642

Finding 1156336 (2024-002)

Material Weakness 2024

Colorado Village Collaborative

CO

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...

Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025

View Audit 368632 Questioned Costs: $1

Finding 1156330 (2024-010)

Material Weakness 2024

McR Health, Inc.

FL

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.

View Audit 368617 Questioned Costs: $1

Finding 1156215 (2024-002)

Material Weakness 2024

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...

Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024

View Audit 368574

Finding 1155989 (2024-002)

Material Weakness 2024

Mountain Home Montana, INC

MT

Matching / Level of Effort / Earmarking § 200.302 § 200.306

With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance wit...

With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance with federal grant matching requirements. The new policy and procedures are attached.

View Audit 368458

Finding 1155972 (2024-003)

Material Weakness 2024

Town of Zionsville

IN

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 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: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the find...

Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Below is the process for submitting required grant reporting. 3. The Director will input the required information 4. Prior to submission of the report, the Director will have the Deputy Director verify the information that has been entered against the supporting documentation. 5. The Deputy Director will let the Director know if it is ok to submit the report. 6. The Director will submit and print a completed submission document that the Deputy Director will verify again. 7. The Deputy Director and Director will both sign and date the completed report. 8. This will be filed for audit purposes. Anticipated Completion Date: This is already taking place. The 2025 filing in April followed this process.

View Audit 368381

Finding 1155968 (2024-004)

Material Weakness 2024

Democracy at Work Institute

CA

Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.302 § 200.305 § 200.306

DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will d...

DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will develop a match policy to include documented review and signed document retention for matching contributions, ensuring compliance with CFR §200.306. a. We will then follow this policy and retain signed documentation of matching contributions. Proposed Completion Date – October 31, 2025

View Audit 368378

Finding 1155888 (2024-002)

Material Weakness 2024

Nevada Rural Hospital Partners, Inc.

NV

Matching / Level of Effort / Earmarking

Management has put procedures in place in the current year to ensure timely submission.

View Audit 368271

Finding 1155835 (2024-002)

Material Weakness 2024

Bay County, Florida

FL

Cash Management Subrecipient Monitoring Eligibility § 200.303

Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any rev...

Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any reviews will be documented with an approval via a formal email confirmation. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail

View Audit 368223

Finding 1155834 (2024-001)

Material Weakness 2024

Bay County, Florida

FL

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion ...

Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail

View Audit 368223

Finding 1155757 (2024-004)

Material Weakness 2024

Sangamon Valley Public Water District

IL

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Eligibility

1. Will create a federal procurement compliance checklist before applying for another contract by a federal award. 2. Will hire legal counsel familiar with federal awards to review the contract. 3. Will request that the engineers amend/revise the Grunloh contract and any other contract issues as par...

1. Will create a federal procurement compliance checklist before applying for another contract by a federal award. 2. Will hire legal counsel familiar with federal awards to review the contract. 3. Will request that the engineers amend/revise the Grunloh contract and any other contract issues as part of the EPA loan to come into compliance with the statute and grant-specific requirements for procurement language.

View Audit 368100

Finding 1155725 (2024-001)

Material Weakness 2024

The Housing Authority of the City of Greenville

SC

HUD Housing Programs Eligibility Significant Deficiency

The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and som...

The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. TGHA files were fully in order by July 2025.

View Audit 368012

Finding 1155719 (2024-001)

Material Weakness 2024

San Antonio Community Hospital

CA

Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking

Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidenc...

Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management implemented corrective action on December 31, 2024 to ensure evidence of controls is retained. Responsible Party: Wah-chung Hsu, Chief Financial Officer Completed Date: December 31, 2024

View Audit 368006

Finding 1155697 (2024-003)

Material Weakness 2024

Trinidad Ambulance District

CO

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

Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Respon...

Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Responsible for Corrective Action: Gabriel Moreno, Executive Director. Anticipated Date of Completion: December 31, 2025

View Audit 367985

Finding 1155683 (2024-002)

Material Weakness 2024

City of South Bend

IN

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct G...

Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct Grant Compliance Requirement: Special Tests and Provisions - Underwriting Requirements Audit Findings: Significant Deficiency Condition: The Consortium did not have a documented review control in place to ensure the underwriting calculation was prepared, reviewed, and maintained. Context: In a sample of three, the following items were noted: • For the first selection, project underwriting support was not available. The underwriting calculation was prepared by a former employee. Review of the calculation was also performed by a former employee. The Consortium does not have record of the calculation. • For the second selection, the underwriting calculation did not have formal sign off by the reviewer. Only the preparer signed the calculation. • For the third selection, the underwriting calculation did not have formal sign off by the preparer. Only the reviewer signed the calculation. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a system of internal controls to ensure the required underwriting calculations are prepared, reviewed, and maintained. Responsible Party and Timeline for Completion: The Consortium Director (or their designee) and the Federal Grant Administrator are responsible for implementation, which will go into effect immediately.

View Audit 367949

Finding 1155663 (2024-001)

Material Weakness 2024

Cahaba Medical Care Foundation

AL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of tim...

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss

View Audit 367937

Corrective Action Plans

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