Corrective Action Plans

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

Finding 1155537 (2024-001)

Material Weakness 2024

The Domestic and Foreign Missionary Society of the Protestant Episcopa

NY

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

To ensure compliance with applicable regulations, the Domestic and Foreign Missionary Society (Society) requires employee whose compensation is charged to the Federal grant-funded programs to complete monthly timesheets to document their actual time spent on those programs. In two instances, employe...

To ensure compliance with applicable regulations, the Domestic and Foreign Missionary Society (Society) requires employee whose compensation is charged to the Federal grant-funded programs to complete monthly timesheets to document their actual time spent on those programs. In two instances, employees whose compensation was charged to the programs were terminated from employment and did not complete time sheets prior to their termination. Supervisors were subsequently able to verify the allocation of their time to the programs and the amounts charged to grants, and the audit did not note any instances of noncompliance. Management will strengthen internal controls in the future to ensure that final time sheets are obtained and verified by supervisors prior to the termination of any employees whose compensation is charged to the programs.

View Audit 367833

Finding 1155523 (2024-002)

Material Weakness 2024

I Be Black Girl

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

IBBG will develop and adopt a written procurement policy that is consistent with the Uniform Guidance, 2 CFR §§200.318–200.326, and applicable state and local laws. The policy will outline procurement methods, competitive bidding requirements, conflicts of interest, and documentation standards. In a...

IBBG will develop and adopt a written procurement policy that is consistent with the Uniform Guidance, 2 CFR §§200.318–200.326, and applicable state and local laws. The policy will outline procurement methods, competitive bidding requirements, conflicts of interest, and documentation standards. In addition: • A draft policy will be prepared by the I Be Black Girl leadership, the finance committee, and D&K Financial LLC. • The Board of Directors will adopt the final policy. • Training will be provided to staff involved in procurement to ensure consistent implementation of the procurement process.

View Audit 367814

Finding 1155517 (2024-001)

Material Weakness 2024

Susan Laflesche Picotte Center

NE

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.318 § 200.326

Management Response: The Organization will establish a procurement policy in 2025. Anticipated Completion Date: 12/31/2025 Responsible Party: Board of Directors

View Audit 367803

Finding 1155467 (2024-003)

Material Weakness 2024

Wisconsin Regional Training Partnership INC

WI

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.201 § 200.303 § 200.327

WRTP has reviewed the organization’s fiscal policy manual including all subsections regarding contractual provisions and procurement. Additional training has been provided and completed by management and staff. The fiscal policy manual procurement section will undergo further review by a third party...

WRTP has reviewed the organization’s fiscal policy manual including all subsections regarding contractual provisions and procurement. Additional training has been provided and completed by management and staff. The fiscal policy manual procurement section will undergo further review by a third party and if recommended, will be updated and presented to the Finance Committee of the Board of Directors.

View Audit 367749

Finding 1155453 (2024-005)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file...

B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file out of compliance sub recipient forms per the timetable noted in Section D below. C. Timetable of dates for performance of planned corrective action steps including completion date: Slated to begin new process August 1, 2025 for new contracts and/or contract renewals. Once process has been finalized, ACHD Fiscal will also review past agreements that are still in effect. D. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Financial Manager and Grants Manager will ensure lists and monitoring activities are maintained.

View Audit 367739

Finding 1155451 (2024-012)

Material Weakness 2024

County of Allegheny, Pennsylvania

PA

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking

We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by ...

We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by individual grants. All match from all HUD programs is added together and submitted on one ﬁnal report at the end of each funding year. The requirement is 25% on all budget lines except for Leasing. However, if one program’s match is short of the 25% requirement, the overall CoC is responsible for the ﬁlll match, so additional DHS admin costs are used to represent the additional match needed. For our FY23-24 annual report to HUD, we submitted 32.94% in match for the overall ﬁmding. This amount did not include any additional HMIS (data system) costs, Allegheny Link (our coordinated entry system) costs or additional DHS admin costs. With these additional eligible activities, our matching amount could have been over 50%. Therefore, even if some identiﬁed items were considered ineligible our match would not be in jeopardy since we have a lot of eligible costs that DHS covers that would be considered match.

View Audit 367739

Finding 1155427 (2024-004)

Material Weakness 2024

Forth Mobility Fund

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findi...

2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action Plan: Effective September 30, 2024, we established written policies and procedures regarding tracking and reporting first-tier subawards under the Federal Funding Accountability and Transparency Act. Moving forward, we will strengthen these procedures by incorporating an additional review step to ensure compliance with federal special reporting requirements. This added oversight will help maintain accuracy, consistency, and accountability in the reporting process. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2025

View Audit 367713

Finding 1155426 (2024-003)

Material Weakness 2024

Forth Mobility Fund

OR

Cash Management Internal Control / Segregation of Duties Material Weakness § 200.303

2024-003. Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost-reimbursement related to federal grants which include proper segregation of duties. Explanation of disag...

2024-003. Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding invoicing for cost-reimbursement 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 Plan: Effective October 31, 2024, we implemented proper segregation of duties for preparing and submitting cost-reimbursement invoices related to federal grant awards. Under this procedure, the Grants Accountant prepares the invoice, and the Senior Finance Manager reviews and documents approval in writing. This segregation of duties has been incorporated into our written policies and procedures. In the event of any staffing changes or vacancies, responsibilities are reassigned among available finance staff and contracted accountants to ensure that preparation and review functions remain segregated at all times. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Rachel Pippin, CMA, Senior Finance Manager Plan completion date for corrective action plan: September 30, 2025

View Audit 367713

Finding 1155412 (2024-001)

Material Weakness 2024

Imagine Housing and Affiliates

WA

HUD Housing Programs Reporting Matching / Level of Effort / Earmarking

Finding 2024-001: For the year ending December 31, 2023, the Corporation did not submit the Data Collection Form to the Federal Audit Clearinghouse in the time period required by Uniform Guidance. Comments on the Finding and Each Recommendation: The Corporation should submit the Data Collection Form...

Finding 2024-001: For the year ending December 31, 2023, the Corporation did not submit the Data Collection Form to the Federal Audit Clearinghouse in the time period required by Uniform Guidance. Comments on the Finding and Each Recommendation: The Corporation should submit the Data Collection Form to the Federal Audit Clearinghouse within the required time period. Management agrees with the finding and recommendation. Action(s) taken or planned on the finding: The Data Collection Form for the year ended December 31, 2023, was submitted on December 18, 2024.

View Audit 367675

Finding 1155370 (2024-004)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1...

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1, 2025

View Audit 367616

Finding 1155369 (2024-003)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Ac...

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: September 18, 2025

View Audit 367616

Finding 1155367 (2024-001)

Material Weakness 2024

Suffolk County, New York

NY

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant...

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

View Audit 367602

Finding 1155356 (2024-002)

Material Weakness 2024

Jewish Family & Children's Service of Southern Arizona, Inc.

AZ

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

Management reviewed their internal control policies and procedures and made changes to accounting operations to resolve this issue going forward.

View Audit 367600

Finding 1155283 (2024-003)

Material Weakness 2024

Housing Authority of Pikeville

KY

Reporting Matching / Level of Effort / Earmarking

Management has been pursuing changes in MINC access to ensure required access is in place to input and submit required reports. This process is close to being complete and should allow us to submit required reporting.

View Audit 367530

Finding 1155282 (2024-002)

Material Weakness 2024

Housing Authority of Pikeville

KY

Cash Management HUD Housing Programs Matching / Level of Effort / Earmarking § 200.305

Management will review and retrain to insure that capital fund expenditures are drawn down prior to payment.

View Audit 367530

Finding 1155268 (2024-003)

Material Weakness 2024

Town of Ridgeville

IN

Allowable Costs / Cost Principles Material Weakness Period of Performance § 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: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Responsible Officia...

FINDING 2024-003: Finding Subject: COVID 19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Toni Loper, Town Clerk-Treasurer Contact Phone Number and Email Address: 765-857-2377 / ridgevilleclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In regards to the current finding over the reporting period under audit all pertinent issues will be corrected in the following annual project and expenditure report, due in April, 2026. The town will contract with Local Government Services to prepare the annual project and expenditure report, develop a procedure where the Clerk-Treasurer or any Town employee with proper training and knowledge will review the report prior to submission for accuracy and completeness before final filing. The Clerk-Treasurer or respective town employee who will review the report, will receive the proper training over the respective program. Any correspondence between Local Government Services and the Town of Ridgeville will be documented accordingly. Anticipated Completion Date: Policies and procedures to be documented and adopted by March 18, 2026. Full implementation and testing to be in place for the 2025 fiscal year reporting cycle.

View Audit 367501

Corrective Action Plans

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