Corrective Action Plans

Finding 573272 (2024-002)

Significant Deficiency 2024

IL

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

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP con...

Finding Reference Number: 2024-02 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that monthly replacement reserve deposits are made in accordance with the HAP contract. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Billie Williams, President of Active Real Estate Management Completion Date: Open

View Audit 364065

Finding 573227 (2024-001)

Material Weakness 2024

Vermont Youth Conservation Corp, Inc.

VT

Questioned Costs Matching / Level of Effort / Earmarking Reporting

Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. ...

Recommendation: Vermont Youth Conservation Corps, Inc. should put procedures In place to ensure that they are in compliance with grant agreements and that all required matching dollars are satisfied in the respective award period. Action Taken: Vermont Youth Conservation Corps, Inc. has implemented procedures to ensure grant matching requirements are satisfied at the time of final report submission. If Corporation for National and Community Service (CNCS) has any questions regarding this plan, please call Hapy Mayer at (802) 434-3969 ext. 134.

View Audit 364046 Questioned Costs: $1

Finding 573214 (2024-002)

Material Weakness 2024

East Phillips CO Hospital Dist Dba Melissa Memorial Hospital

CO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses...

Corrective action planned: Department managers and others involved in grants will be educated on the importance of understanding the types of grants they are requesting or receiving including any reporting requirements. Accounting staff will assist with the matching of grant revenues and expenses to verify that they are appropriate and in the correct accounting period. A procedure will be implemented to ensure that at year-end, all grant revenues and expenses are double-checked to verify they are posted in the correct period. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO

View Audit 364026

Finding 573196 (2024-002)

Significant Deficiency 2024

City of Topeka, Kansas

KS

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The re...

Management’s Response/Corrective Action Plan (Unaudited): To ensure accuracy and accountability in ARPA report submissions, one staff member will prepare the spreadsheet detailing quarterly figures, and a second staff member will review and confirm the data in writing to the initial preparer. The report will then be completed and submitted as the official report. The approval will be documented via email or other written confirmation. All approval records will be saved in the designated quarterly report file at or before the time of submission. If another staff member prepares or adjusts the report (e.g., due to leave), they will also document and save evidence of approval in the designated quarterly report file. Moving forward, the City will consistently retain documented approvals as part of the reporting process. Planned Completion Date: These modifications are being implemented immediately. Contact Person Responsible for Correction Action: Joshua McAnarney, Division Director of Finance & Budget or Designee

View Audit 364022

Finding 573161 (2024-001)

Significant Deficiency 2024

Clear Path for Veterans New England, Inc.

MA

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

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility ...

Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Clear Path for Veterans New England, Inc. is in the process of enhancing its internal controls over eligibility to ensure that participants are recertified within the allowable time frame. Anticipated Completion Date September 2025

View Audit 363979

Finding 573160 (2024-002)

Significant Deficiency 2024

New Jersey City University

NJ

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedu...

The finding resulted from a manual error. The University will evaluate the existing review process to ensure it operates with the level of precision necessary to detect such discrepancies. Additionally, targeted training will be provided to staff, where applicable, to reinforce proper review procedures and reduce the risk of future manual errors.

View Audit 363978

Finding 573159 (2024-001)

Material Weakness 2024

New Jersey City University

NJ

Student Financial Aid Subrecipient Monitoring Cash Management

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...

The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.

View Audit 363978

Finding 573158 (2024-003)

Significant Deficiency 2024

Hawaiian Shores Community Association

HI

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

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit fi...

Communities Facilities Loans and Grants – Assistance Listing No. 10.766 Recommendation: We recommend the Association implement a process whereby transfers are set up to be automatically made on a monthly basis to ensure compliance with loan requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Association will make the required transfers in fiscal year 2025 to ensure compliance with loan requirements. Name of the contact person responsible for corrective action: Jeff Sargent Planned completion date for corrective action plan: May 1, 2025

View Audit 363975

Finding 573121 (2024-001)

Material Weakness 2024

The Addiction Center of Broome County, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal proces...

Corrective Action Plan for FYE December 31, 2024 Finding 2024-001 Corrective Action Plan: Management will implement periodic time studies throughout contract durations to support accurate allocation of personnel costs. Staff will be reminded of relevant compliance requirements, and internal processes will be adjusted as needed. We will continue to monitor this area and document efforts to ensure ongoing alignment with applicable regulations. Contact Person Responsible for Corrective Action Plan: Lottie Albrecht, Director of Administration Phone Number: 607-940-0102 Email: lalbrecht@acbcservices.org Anticipated Completion Date of Corrective Action Plan: December 2025 (as part of preparation for fiscal year ending December 31, 2025)

View Audit 363928 Questioned Costs: $1

Finding 573036 (2024-001)

Material Weakness 2024

Banner Health

AZ

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

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reve...

Internal control deficiency over activities allowed or unallowed and allowable costs/cost principles related to review of contract labor expenditures. Banner requires control labor resources to utilize the same time keeping system used by Banner employees to track worked time. Banner creates ‘reverse invoices’ using the time tracked in Banner’s timekeeping system by contract labor resources and presents those hours/dollars to contract labor agencies for approval prior to remitting payment to those agencies. These invoices are reviewed by Banner’s staffing services team for reasonableness prior to being presented to the agencies for approval. There is an expectation that managers review and formally approve the timecards of contract labor resources in the timekeeping system, however, the reverse invoicing process moves forward even in the absence of a documented formal approval. Banner will implement a periodic monitoring process that provides a report of ‘forced sign offs’ (timecards without documented manager approval) to senior leadership in an effort to increase compliance with the timecard approval policy. Contact: Paul Nolde-Morrissey, Vice President and Corporate Controller Expected completion date: September 30, 2025

View Audit 363912

Finding 573035 (2024-002)

Significant Deficiency 2024

Warren County, Missouri

MO

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

The County will work diligently to implement internal controls over its federal award program to ensure accurate reporting of any activity.

View Audit 363908

Finding 573029 (2024-009)

Material Weakness 2024

City of Nogales Arizona

AZ

Special Tests & Provisions Procurement, Suspension & Debarment Material Weakness § 200.303 § 200.326

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: ...

2024 – 009 Special Tests and Provisions – Wage Rate Federal Agency: Department of Interior Federal Program Title: Outdoor Recreation Acquisition, Development and Planning ALN: 15.916 Pass-Through Agency: Arizona State Park Trails Pass-Through Number(s): 04-007-652304 Award Number and Period: 04/18/2022-12/31/24 Statistically Valid Sample: No, and not intended to be a statistically valid sample Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Condition/Context: There was no support provided for the three out of three contractor vendors with construction work noted on their purchase orders to support compliance with Davis Bacon. Corrective Action Plan: Regarding the wage tests for the Park’s grant, no information was provided to the City from the contractor of employee wages paid by the contractor. An email request and answer from the contractor was forwarded to the auditors, that the contractor was not responsible to report the wages. This in the future will be part of the Grants Coordinator position for Internal Control purposes, to ensure that any future construction contracts include the wage reporting requirements. Anticipated completion date: December 2025 Contact Person: Mr. Joel Kramer, City Manager

View Audit 363891

Finding 572993 (2024-002)

Significant Deficiency 2024

La Clinica Tepeyac

CO

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

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...

Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.

View Audit 363862

Finding 572979 (2024-001)

Significant Deficiency 2024

King County Public Hospital District #2 Dba Evergreen Healthcare

WA

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303 § 200.403

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...

AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.

View Audit 363843 Questioned Costs: $1

Finding 572976 (2024-002)

Significant Deficiency 2024

Open Doors for Multicultural Families

WA

Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct t...

We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct the issue as of June 1, 2025. The Accounting Manager will send the monthly indirect cost allocation report to the Executive Director to review and approve prior to beginning any month-end billing process so if corrections are needed, they can be made prior to reimbursement requests being sent to the grant agency. We have also implemented a new month-end process as of June 1, 2025, for the Accounting Manager to provide a detailed GL report to each Program Manager to review and approve program expenses for the given month prior to any billing requests being submitted to the grant agency.

View Audit 363824

Finding 572973 (2024-001)

Significant Deficiency 2024

Open Doors for Multicultural Families

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospect...

We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospective contractors will be entered into the Sam system and scanned for debarment prior to contracting with them by the Program Manager. In addition, we are in the process of updating our vendor agreements to include language so a vendor can attest they are not debarred from doing business with the federal government.

View Audit 363824

Finding 572971 (2024-002)

Material Weakness 2024

City of Marshalltown

IA

HUD Housing Programs Material Weakness Reporting § 200.303

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified i...

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified in which the City did not use accurate financial information or retain evidence to document the individual who reviewed the Voucher Management System (VMS) reports prior to submission. Responsible Individual: Diana Steiner, Finance Director Corrective Action Plan: We agree with the auditor’s recommendation and staff will have asecond person review the reports. Anticipated Completion Date: By the completion of the ACFR for the fiscal year ending June 30, 2025.

View Audit 363814

Finding 572623 (2024-003)

Significant Deficiency 2024

Del Norte Child Care Council

CA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.512

Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the d...

Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to provide financial oversight. Action: Develop procedures to ensure required single audits are completed and submitted to the Federal Audit Clearinghouse by the 9-month due date. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director Carrie Castillo, Executive Director, is the official responsible for implementing each corrective action plan.

View Audit 363736

Finding 572622 (2024-002)

Material Weakness 2024

Del Norte Child Care Council

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being up...

Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director

View Audit 363736

Finding 572619 (2024-003)

Material Weakness 2024

City of Poplar Bluff

MO

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Finding Type: Internal Controls over Federal Programs. Name of Contact Person: Mr. Robert Knodell, City Manager, (573) 686-8620. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to...

Finding Type: Internal Controls over Federal Programs. Name of Contact Person: Mr. Robert Knodell, City Manager, (573) 686-8620. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: We will ensure we comply going forward. Proposed Completion Date: Immediately.

View Audit 363734

Finding 572589 (2024-004)

Material Weakness 2024

Decatur County

IN

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

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Christy Smiley Contact Phone Number and Email Address: 812-663-2570, auditor@decaturcounty.in.gov Views of Responsible Officials: We concur with ...

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Christy Smiley Contact Phone Number and Email Address: 812-663-2570, auditor@decaturcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 27 At least 2 people will look over the report and check all receipts and expenditures when the next P&E report is submitted to prevent and detect any errors. Prior P&E report had already been submitted before the prior audit was complete and we were made aware of the issue and then the Auditor changed in 2025. Control will not be in place until the 2026 P&E report is submitted. Anticipated Completion Date: Submission of next ARPA report, April 2026.

View Audit 363722

Finding 572516 (2024-002)

Significant Deficiency 2024

City of Peoria, Illinois

IL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

The City’s Finance Department is working with the Fire Department to install the proper internal controls over the preparation of the performance reports. Going forward, the reports that are prepared by the City’s Fire Chief will be reviewed by the City’s Finance Department to ensure accuracy and co...

The City’s Finance Department is working with the Fire Department to install the proper internal controls over the preparation of the performance reports. Going forward, the reports that are prepared by the City’s Fire Chief will be reviewed by the City’s Finance Department to ensure accuracy and compliance.

View Audit 363673

Finding 572455 (2024-002)

Significant Deficiency 2024

Beaumont Cherry Valley Water District

CA

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.328

Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checkli...

Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checklists or reconciliation processes, and provide training to staff involved in federal reporting. Corrective Action: 1. Assign separate personnel for report drafting and supervisory review to ensure segregation of duties. 2. Create and require use of a Quarterly Report Review Checklist to confirm accuracy, completeness, and timeliness before submission. Person Responsible for Corrective Action: William Clayton, Finance Manager. Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

View Audit 363593

Finding 572417 (2024-002)

None 2024

University of Pennsylvania

PA

Student Financial Aid Subrecipient Monitoring Reporting

Student Registration and Financial Services (SRFS) and the office of Student Financial Aid (SFA) will continue collaboration with school partners and the office of the Provost to reinforce university policies and procedures by continuing to provide training to individuals involved in the process of ...

Student Registration and Financial Services (SRFS) and the office of Student Financial Aid (SFA) will continue collaboration with school partners and the office of the Provost to reinforce university policies and procedures by continuing to provide training to individuals involved in the process of updating student’s enrollment. The office of the University Registration (OUR) and SFA will collaborate to use existing school partner meetings, and internal functional partner meetings to conduct training. OUR generated its first Enrollment Reporting out of the new system (Banner Student) in Summer 2022. We expect to achieve steady state processing, when moving from the main frame to ERP system within five years of go-live. SRFS will review school partner access through audit reports to determine error rates and assess risk. SRFS will review existing policy/practice around student activated drops/withdrawals/Penn Leaves of Absence and make recommendations.

View Audit 363547

Finding 572354 (2024-001)

Material Weakness 2024

City of Springfield

MA

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

Views of Responsible Officials and Planned Corrective Actions: Management agrees and plans to provide for additional training to ensure those preparing and reviewing the reports have the appropriate understanding and information to ensure accuracy and completeness in the information being reported. ...

Views of Responsible Officials and Planned Corrective Actions: Management agrees and plans to provide for additional training to ensure those preparing and reviewing the reports have the appropriate understanding and information to ensure accuracy and completeness in the information being reported. Management will create, to review and sign, a "checklist" of requirements needed to ensure compliance with the program's rules. The checklist will be reviewed, and incorporated into the minutes, as part of the weekly ARPA Oversight Meetings. The checklist will be completed and signed by management prior to submitting any reports. Past reports will be reviewed and corrected prior to submission of the next quarterly report. All changes will be incorporated into the City's controls prior to the submission of the next quarterly report due April 30, 2025.

View Audit 363426

Corrective Action Plans

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