Corrective Action Plans

Finding 571506 (2024-002)

Material Weakness 2024

McNary Elementary School District No. 23

AZ

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.333

The District will aggregate and reconcile all application documentation and scan all supporting documentation and place in a secured central location electronically and/or physically.

View Audit 362459

Finding 571503 (2024-006)

Material Weakness 2024

City of Loveland

CO

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.502 § 200.508 § 200.510

Condition: The schedule of expenditures of federal awards (the "SEFA") was not accurate. Planned Corrective Action: To improve accuracy and completeness of the SEFA, the City will enhance its master grant tracking spreadsheet to ensure all grant expenses are calculated correctly and consistently. I...

Condition: The schedule of expenditures of federal awards (the "SEFA") was not accurate. Planned Corrective Action: To improve accuracy and completeness of the SEFA, the City will enhance its master grant tracking spreadsheet to ensure all grant expenses are calculated correctly and consistently. In addition, quarterly reviews will be conducted in partnership with departments to confirm that all federal awards are current and accurately captured. These improvements, along with the updated required quarterly report and request for reimbursement procedures, will allow the City to compile a complete and accurate SEFA. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 7/31/2025

View Audit 362454

Finding 571502 (2024-005)

Material Weakness 2024

City of Loveland

CO

Procurement, Suspension & Debarment Material Weakness Matching / Level of Effort / Earmarking

Condition: The City did not have controls in place surrounding the review of contracts and bid documents and omitted the prevailing wage rates provisions from the construction contract it entered into that was financed by the federal award. Planned Corrective Action: While the City did have sufficie...

Condition: The City did not have controls in place surrounding the review of contracts and bid documents and omitted the prevailing wage rates provisions from the construction contract it entered into that was financed by the federal award. Planned Corrective Action: While the City did have sufficient internal policy in place to ensure compliance with 2 CFR 200 procurement requirements, the City failed to follow such procedures, despite compliance in practice. To address this, the City will revise both its Grants Management and Procurement Administrative Regulations to ensure that all required federal provisions are explicitly included in all applicable solicitations and contracts. Updated procedures will reinforce alignment between policy and practice. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 7/31/2025

View Audit 362454

Finding 571500 (2024-003)

Material Weakness 2024

City of Loveland

CO

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

Condition: The City did not have controls in place surrounding the review of requests for reimbursement to ensure the underlying invoices were allowable and that the local matching contribution was calculated correctly. Planned Corrective Action: The City will revise its Grants Management Administra...

Condition: The City did not have controls in place surrounding the review of requests for reimbursement to ensure the underlying invoices were allowable and that the local matching contribution was calculated correctly. Planned Corrective Action: The City will revise its Grants Management Administrative Regulation to require that all requests for reimbursement be submitted on a quarterly basis. Each RFR will be required to go through a documented review by a finance staff member prior to submission to ensure accuracy and appropriate application of required match. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 07/31/2025

View Audit 362454

Finding 571499 (2024-002)

Material Weakness 2024

City of Loveland

CO

Reporting Material Weakness Matching / Level of Effort / Earmarking § 200.303

Condition: The City did not have controls in place surrounding the filing of semi-annual performance and financial reports nor did it submit the required reports. Planned Corrective Action: Ensure that all annual reports for all federal programs have a required secondary review by a finance staff me...

Condition: The City did not have controls in place surrounding the filing of semi-annual performance and financial reports nor did it submit the required reports. Planned Corrective Action: Ensure that all annual reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy, and timeliness of submission. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 6/30/2025

View Audit 362454

Finding 571498 (2024-001)

Material Weakness 2024

City of Loveland

CO

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy...

Condition: The City did not have controls in place surrounding the review of annual performance reporting. Planned Corrective Action: Ensure that all quarterly reports for all federal programs have a required secondary review by a finance staff member before submission to ensure compliance, accuracy, and timeliness of submission. Contact person responsible for corrective action: Grant Accountant and Accounting Manager Anticipated Completion Date: 6/30/2025

View Audit 362454

Finding 571488 (2024-001)

Material Weakness 2024

Deschutes Land Trust

OR

Reporting Internal Control / Segregation of Duties Material Weakness § 200.303

WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there i...

WaterSMART – Assistance Lising #15.507 Recommendation: The Organization should establish written policies and procedures regarding internal control over financial reporting related to federal grants, which include proper segregation of duties. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: Ensure the Stewardship Director reviews and signs the SF-425. Action Plan: Amend existing policies associated with federal grants, to require the Program Director responsible for overseeing projects using federal funds to sign any required and submitted financial reports. Name(s) of the contact people responsible for correction action: Michael Rubovits Plan completion date for corrective action plan: 8/31/2025

View Audit 362417

Finding 571482 (2024-003)

Significant Deficiency 2024

Eastern Plains Community Action Agency, Inc.

NM

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking

We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy ...

We have never had monthly board or policy council meetings, but we upload monthly reports including financials to our portal for board and policy council members to reveiw and comment. Our meetings have always been quarterly. In addition, we already have the EPCAA Governance Program Planning Policy in place to correct this finding that was approved by the board on August 9, 2024.

View Audit 362404

Finding 571467 (2024-002)

None 2024

Healthfirst Bluegrass INC

KY

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking

Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit t...

Views of responsible officials and planned corrective actions – Management has begun staff training and will meet with the billing team regarding the sliding fee policy and process, including scanning of application into the patient's file. Management will ensure HFBG continues to apply and audit the application of sliding fee discounts on the patient accounts consistent with policy.

View Audit 362384

Finding 571464 (2024-006)

Significant Deficiency 2024

City and County of Denver

CO

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

Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recom...

Federal Program Name: Community Development Block Grants/Entitlement Grants – Assistance Listing No. 14.218 Compliance Requirement: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Type of Finding: Significant Deficiency in Internal Control over Compliance, Other Matters Recommendation: We recommend the City establish and implement a formal process to consistently retain documentation of FFATA report submission dates, as well as evidence of the review and approval of each report submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action taken in response to finding: Denver’s Department of Economic Development and Opportunity (DEDO) will establish a formal approval process to establish and document submission dates of all FFATA filings going forward. While the Federal Government does not provide any timestamps of initial submission for FFATA filings, nor require approval for FFATA submissions, DEDO will begin providing written and dated approvals of when FFATA reporting is taking place. We will put together a formal process that will provide dates to show review/approval of FFATA filings to meet our external auditor’s request, despite the Federal Government not requiring it. DEDO is able to provide a documented historical consistency of maintaining effective internal controls over this Federal award, and will begin including FFATA filings in the documentation that is already maintained showing timely submission of reporting to the Federal Government. Name(s) of the contact person(s) responsible for corrective action: Fanta Harkiso & Derek Cary Planned completion date for corrective action plan: August 31, 2025

View Audit 362374

Finding 571462 (2024-005)

Significant Deficiency 2024

City and County of Denver

CO

Matching / Level of Effort / Earmarking § 200.303

Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user acce...

Federal Program Name: Child Care and Development Fund Cluster – Assistance Listing No. 93.575, 93.596 Compliance Requirement: Eligibility Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the City implement a control to ensure the CBMS user access rights are offboarded timely when employees separate employment or move departments that do not require them to keep CBMS access. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Add Second Level verification: DHS Help Desk supervisor will be copied on Departure notices from Human Resources. The DHS Help Desk Supervisor will match IAM offboard notices from State OIT to Internal Human Resources Departure notices on a weekly basis and follow-up on any unmatched items. Name(s) of the contact person(s) responsible for corrective action: Carl Ellis, TS IT Supervisor Planned completion date for corrective action plan: April 1, 2025

View Audit 362374

Finding 571438 (2024-004)

Material Weakness 2024

Town of Paoli

IN

Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Descrip...

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately

View Audit 362372

Finding 571391 (2024-001)

Material Weakness 2024

St. Vincent General Hospital District

CO

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...

Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.

View Audit 362330

Finding 571386 (2024-001)

Material Weakness 2024

City of Laporte

IN

Internal Control / Segregation of Duties Special Tests & Provisions HUD Housing Programs § 200.303

FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary ...

FINDING Section III – Internal Controls - CDBG Contact Person Responsible for Corrective Action: Mary Ann Richards, CDBG Program Manager Contact Phone Number: (219) 362-8260 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Reporting-Financial Summary Report (PR26) The City of La Porte Community Development Block Grant will submit the following report to the Clerk/Treasurer and Director of Community Development and Planning for review and approval prior to submitting to HUD: PR26 Annual Financial Summary. Special Tests and Provisions - Environmental Reviews The City of La Porte Community Development Block Grant will develop a checklist listing forms and correspondence required when completing an environmental review. The Director of Community Development and Planning will review the environmental review file and sign the checklist thereby indicating the environmental review is complete and properly maintained. Special Tests and Provisions – Rehabilitation The City of La Porte Community Development Block Grant will develop a evaluation form for the Director of Community Development and Planning to review to compare the initial site visit, work scope, and certificate of completion is properly maintained. The Community Development Block Grant program manager will initiate the form for review by the Director of Community Development and Planning at the end of the rehab activity per address. Anticipated Completion Date: July 1, 2025

View Audit 362316

Finding 571254 (2024-003)

Material Weakness 2024

Rccc Villa

IA

HUD Housing Programs Matching / Level of Effort / Earmarking

We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.

View Audit 362177

Finding 571253 (2024-002)

None 2024

Rccc Villa

IA

HUD Housing Programs Matching / Level of Effort / Earmarking

We will develop a procedure to ensure the required monthly deposits to the replacement reserve are made timely.

View Audit 362177

Finding 571166 (2024-002)

Material Weakness 2024

Midmichigan Health Services

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Finding Number: 2024-002 Condition: Internal control procedures were not documented with enough evidence to support reports were being reviewed throughout the year. Additionally, due to entries identified and recorded during the 2024 financial statement audit of the Company, the data submitted with...

Finding Number: 2024-002 Condition: Internal control procedures were not documented with enough evidence to support reports were being reviewed throughout the year. Additionally, due to entries identified and recorded during the 2024 financial statement audit of the Company, the data submitted within the annual performance report was not accurate. Planned Corrective Action: Since the FY 2024 financial and single audit adjustments were not discovered and completed prior to the UDS submission deadline of 3/31/2025 and there is no mechanism to change UDS values after the deadline we will move the audit engagement earlier in the 2026 year to allow time to correct any UDS issues prior to 3/31/2026 deadline. Contact person responsible for corrective action: William E Collin, CFO Anticipated Completion Date: 3/31/2026

View Audit 362079

Finding 571154 (2024-003)

Material Weakness 2024

Hinds Community College District

MS

Questioned Costs Student Financial Aid Special Tests & Provisions

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District did not properly calculate the total amount disbursed or to be disbursed which lead to incorrect calculation of funds to be returned ...

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District did not properly calculate the total amount disbursed or to be disbursed which lead to incorrect calculation of funds to be returned to Title IV. Additionally, the District did not provide evidence of date of determination used in calculation. b. Corrective Action Plan: The District is an attendance taking institutional and has reviewed its internal controls on how total days in the semester are calculated correctly and timely disbursements are made. The District understands that it should be using the Last Day of Attendance in the calculation of earned aid and made that modification Spring 2025 in collaboration with the U.S. Department of Education and outlined the calculation variables to align with that calculation change. Management has revised its Policy and Procedures accordingly and will submit to the Hinds Board of Trustees for final approval December of 2025. The correction implementation date was June 2025 to be finalized December 2025.

View Audit 362076 Questioned Costs: $1

Finding 571153 (2024-002)

Material Weakness 2024

Hinds Community College District

MS

Student Financial Aid Material Weakness Reporting

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services .... Jennifer Scott-Gilmore 601-857-3250 The District did not report timely and accurate student status information to the National Student Loan Data System (NSLDS). The District did not en...

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services .... Jennifer Scott-Gilmore 601-857-3250 The District did not report timely and accurate student status information to the National Student Loan Data System (NSLDS). The District did not ensure internal controls were in place to ensure timely and accurate reporting. b. Corrective Action Planned: The Management has implemented additional organizational and internal controls to ensure students' enrollment statuses are reported timely and accurately. In reviewing the causation of the finding, it was determined that it was a personnel error and as of June 2024, there is a new Registrar for Hinds Community College charged with compliance of this requirement. During the AY2024-25, the Registrar worked within the new student information system (SIS) to generate the required student data on a monthly cycle to be submitted to the National Clearinghouse which is then transmitted to NSLDS. This update in internal controls should satisfy future reviews.

View Audit 362076

Finding 571152 (2024-001)

Significant Deficiency 2024

Hinds Community College District

MS

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District using a Servicer to Deliver Title IV Credit Balances to a card did not provide a URL for the contract to the Department of Education ...

a. Administrator: V.P. Finance/ CFO ....... Victor Parker 601-857-3961 b. Administrator: V.P. Student Services ...... Jennifer Scott-Gilmore 601-857-3250 The District using a Servicer to Deliver Title IV Credit Balances to a card did not provide a URL for the contract to the Department of Education in the Cash Management Contracts Database and disclose the contract on the District's website. b. Corrective Action Planned: The Management has reviewed the District process of delivering Title IV credit balances to students. Management will disclose the third-party contractual agreement to its Servicer as well and provide the URL to the Department of Education via the Cash Management Contracts Database. The anticipated completion date is August 2025.

View Audit 362076

Finding 571143 (2024-001)

Material Weakness 2024

Johnston-Lee Harnett Community Action, Incorporated

NC

Questioned Costs Procurement, Suspension & Debarment Material Weakness

The Fiscal Policies and Procedures will be followed. Any expenses over $5,000 associated with the upkeep of facilities will be reviewed by the Head Start Advisory Committee, approved by the Finance Committee, Executive Committee and/or Board of Directors. Any large facility issues or concerns will b...

The Fiscal Policies and Procedures will be followed. Any expenses over $5,000 associated with the upkeep of facilities will be reviewed by the Head Start Advisory Committee, approved by the Finance Committee, Executive Committee and/or Board of Directors. Any large facility issues or concerns will be reported by the Head Start Director to the Head Start Advisory Committee along with the source of the issue and any cost associated with the repairs. Reporting will be consistent even if the repair qualifies for reimbursement by the State of North Carolina.

View Audit 362054 Questioned Costs: $1

Finding 571008 (2024-002)

Significant Deficiency 2024

City of Brainerd

MN

Matching / Level of Effort / Earmarking Reporting Significant Deficiency

Reporting & Earmarking Federal Agency: U.S Department of Treasury Federal Program Name: Coronavirus State & Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Compliance Requirement Affected: Reporting & Earmark...

Reporting & Earmarking Federal Agency: U.S Department of Treasury Federal Program Name: Coronavirus State & Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Compliance Requirement Affected: Reporting & Earmarking Award Period: FY24 Recommendation: We recommend that the City implement procedures and controls to ensure the required reports are accurate before submitting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action take in response to finding: The City will implement controls to ensure required reports are accurate before submitting. Name of the contact person responsible for corrective action: Connie Hillman, Finance Director Planned completion date for corrective action plan: December 31, 2025

View Audit 361947

Finding 570860 (2024-007)

Material Weakness 2024

Polk County, Iowa

IA

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.303

Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This gr...

Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This grant has ended as of 6/30/25. In the future if we have fiscal agency services, we will ensure the that the program is being properly reviewed and administered.

View Audit 361781

Finding 570678 (2024-003)

Material Weakness 2024

Cumberland County Fiscal Court

KY

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

We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleas...

We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleased to have made progress on this front, but also extremely appreciative for the guidance and feedback from those reporting agencies. KYEM and FEMA document tracking and reporting is now handled entirely inhouse. Members of the Cumberland County Management Team have responded timely and in full to requests for information and we will continue to do so. The lack of certain systems and processes from years past is no longer a concern of the current administration. It is true that work is still needed to organize and understand some of the work from the last several years, but the Management Team believes that the new process will eliminate most of if not all confusion moving forward on any future disasters.

View Audit 361704

Finding 570635 (2024-003)

Material Weakness 2024

The Mirror, Inc.

KS

Matching / Level of Effort / Earmarking

Plan: • CEO and CFO will analyze the needs for additional staffing in the accounting department to ensure appropriate help is available to ensure needed processes and procedures can be completed monthly/annually for all tasks to be complete. Implementation Date: Beginning of Fiscal Year 26- July 1...

Plan: • CEO and CFO will analyze the needs for additional staffing in the accounting department to ensure appropriate help is available to ensure needed processes and procedures can be completed monthly/annually for all tasks to be complete. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Des Martens CEO and Shelby Turner CFO.

View Audit 361664

Corrective Action Plans

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