Corrective Action Plans

Finding 567765 (2024-039)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional ...

Finding 2024-039 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Transitional Medicaid Eligibility Management Views MDHHS agrees with the finding. MDHHS recognizes there are opportunities for improvement to ensure renewals are processed on a timely basis for beneficiaries receiving transitional medical assistance (TMA) Medicaid coverage, however due to time constraints, it was not feasible to manually review and validate all 1,802 beneficiaries queried to ensure they should be terminated from TMA. Also, although beneficiaries might not be eligible for TMA, they may be eligible for other Medicaid aid categories, and this will be determined as part of the department’s corrective action. Planned Corrective Action MDHHS implemented a system enhancement during May 2023 that generates redetermination requests one month in advance to allow additional time for processing and help ensure renewals are processed timely. MDHHS is continuing to update the backlog of cases following the end of the PHE, including those identified in the finding, to determine if the beneficiary should remain on Medicaid or if coverage should be terminated, and expects all existing cases will be reviewed and updated by July 2025. MDHHS will evaluate potential underlying system issues related to the timeliness of TMA renewals and will implement system enhancements if necessary by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567764 (2024-038)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS User Access Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Access Management Section reconciles the users in MiAIMS to the users approved within DSA monthly, resolves discrepancies, and...

Finding 2024-038 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS User Access Management Views MDHHS agrees with the finding. Planned Corrective Action The MDHHS Access Management Section reconciles the users in MiAIMS to the users approved within DSA monthly, resolves discrepancies, and sends an email notification to LOSCs with a summary of the results. Beginning May 2025, the monthly email notification distributed to the LOSCs will emphasize appropriate procedures for granting access, including a reminder to synchronize MiAIMS activations and the DSA final approval to serve as documentation of the activation. By June 2025, MDHHS MiAIMS management and the Access Management Section will begin meeting annually with LOSCs, help desk, and technical staff to review access procedures. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Cynthia Farrell, MDHHS Tim Kwast, MDHHS

View Audit 360209

Finding 567763 (2024-037)

Significant Deficiency 2024

State of Michigan

MI

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

Finding 2024-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS General Controls Management Views For part a., DTMB agrees it had not fully implemented all SOM database specific configurations during the audit period. However, DTMB disagrees these specific configurations created signifi...

Finding 2024-037 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - MiAIMS General Controls Management Views For part a., DTMB agrees it had not fully implemented all SOM database specific configurations during the audit period. However, DTMB disagrees these specific configurations created significant security risks. DTMB has been and continues to follow the manufacturer’s recommendations regarding security configurations. For part b., DTMB agrees with the finding. Planned Corrective Action For part a., DTMB will implement the SOM approved database configurations. For part b., DTMB will review and update internal business processes as needed to ensure privileged Michigan Adult Integrated Management System (MiAIMS) database accounts are reviewed in accordance with SOM Technical Standards. Anticipated Completion Date July 31, 2025 Responsible Individual(s) Nathan Buckwalter, DTMB

View Audit 360209

Finding 567757 (2024-012)

Material Weakness 2024

State of Michigan

MI

Questioned Costs Eligibility Subrecipient Monitoring § 200.516

Finding 2024-012 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children’s Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Chil...

Finding 2024-012 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children’s Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the identified exceptions for parts a. and c. of the finding. However, MDHHS disagrees that 3 Medicaid cases and 20 Children’s Health Insurance Program (CHIP) cases with MAGI determinations cited in part b. did not have case file documentation supporting the beneficiary eligibility determination. The Centers for Medicare and Medicaid Services (CMS) has determined that a reasonable compatibility indicator can be used for CMS audit purposes to determine if the attested income information was electronically verified for MAGI cases and MDHHS disagrees that documentation was not maintained to support the eligibility determination. The SOM MiIntegrate system communicates with various State and federal electronic trusted data sources and sends the information from these sources, along with the beneficiaries’ attested income, to the SOM MAGI Rules Engine where the MAGI eligibility determination is made. As part of the MAGI eligibility determination, a reasonable compatibility test is completed to determine if beneficiary/applicant attested income is within a specified percentage of the electronic trusted data sources or if the attested and verified income are below the threshold for the applicable program. The results of the MAGI eligibility determination are sent back to MiIntegrate using an Account Transfer (AT) packet that contains the results. MiIntegrate then communicates the results to the SOM MAGI Viewer and Bridges using an AT packet and Bridges stores the AT packet number only that can be used to view the details of the AT packet within the SOM MAGI Viewer. The version of the AT packet within the MAGI Viewer also contains a reasonable compatibility indicator that documents the outcome of the reasonable compatibility test and supports the SOM MAGI Rules Engine eligibility decision. MDHHS stores the AT packet information, including facts essential to the eligibility determination, within MiIntegrate and the MAGI Viewer instead of Bridges to help protect and secure the federal income tax data and unemployment data used for the determination. The AT packet for each individual determination can be retrieved from the MAGI Viewer using the AT packet number stored in each beneficiary’s case file within Bridges. MDHHS is not aware of any federal regulations that preclude MDHHS from storing this information in a separate system to help secure the data and restrict access as required by federal and state law. Planned Corrective Action To address the exceptions identified that are not related to MAGI-based income verification results, MDHHS has developed mandatory training protocols for eligibility workers and expects to have the first Medicaid audit focused mandatory training implemented by July 2025. MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained within the electronic case file. MDHHS disagrees it did not maintain case file documentation that supports the beneficiary eligibility determination for MAGI cases and does not intend to take further action. Anticipated Completion Date MDHHS will implement the first Medicaid audit focused training by July 2025. Responsible Individual(s) Logan Dreasky, MDHHS Mariah Schaefer, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567725 (2024-034)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Special Tests & Provisions

Finding 2024-034 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MiLEAP agrees with the finding. Planned Corrective Action To improve compliance and inspection timeliness, MiLEAP took the following key steps: • Increased staffing: In fiscal year 202...

Finding 2024-034 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MiLEAP agrees with the finding. Planned Corrective Action To improve compliance and inspection timeliness, MiLEAP took the following key steps: • Increased staffing: In fiscal year 2024, the Child Care Licensing Bureau (CCLB) initiated the hiring of 22 additional licensing consultants across all eight established regions, significantly increasing statewide capacity. All new consultants began their positions by November 2024. Upon hire, they entered a structured training program with the goal of receiving caseload assignments within six months. This strategic staffing expansion has already led to a 30.0 percent reduction in the average caseload per consultant from 88 to 61 facilities aligning more closely with best practice recommendations and enabling more timely inspections. As these new consultants complete training and receive full caseloads, CCLB anticipates an increase in completed onsite inspections, improved timeliness, and enhanced capacity to meet the growing needs of child care providers. • Enhanced regional oversight: In fiscal year 2025, CCLB established lead worker positions in each child care region. These lead workers support area managers in monitoring consultant caseloads and inspection schedules to ensure annual inspections are completed in compliance with federal requirements. • Process improvements through technology: CCLB continues to utilize the Child Care Hub Information Records Portal in a mobile format, improving data access and streamlining on-site inspections. Providers are encouraged to utilize the system during onsite inspections to facilitate faster and more efficient communication and documentation. Anticipated Completion Date Ongoing Responsible Individual(s) Courtney Adams, MiLEAP Scott Bettys, MiLEAP Erika Bigelow, MiLEAP Monica Sturdivant, MiLEAP

View Audit 360209

Finding 567724 (2024-033)

Significant Deficiency 2024

State of Michigan

MI

Questioned Costs Matching / Level of Effort / Earmarking § 200.516

Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on ...

Finding 2024-033 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MiLEAP and MDHHS agree with the finding. Planned Corrective Action MiLEAP and MDHHS ESA will continue to work together to help ensure compliance with client eligibility requirements by providing guidance on updated policies, processes, and noted trends to local office and BSC staff. On October 1, 2024, MDHHS ESA distributed an ESA memo to BSCs and local offices requiring a Child Development and Care eligibility checklist to be completed and uploaded to the electronic case file at the time of each Child Development and Care application and redetermination to help ensure the authorized hours of care in Bridges does not exceed the client's documented need for hours of childcare services. The ESA memo also requires local offices that have not yet achieved compliance to review a sample of cases monthly and ensure the Child Development and Care eligibility checklist is properly uploaded to the electronic case file. The BSCs receive the monthly results from the local offices and also monitor progress to help ensure compliance. Anticipated Completion Date Ongoing Responsible Individual(s) Lisa Brewer-Walraven, MiLEAP Mariah Schaefer, MDHHS Gayle Vail, MDHHS

View Audit 360209 Questioned Costs: $1

Finding 567723 (2024-032)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Special Tests & Provisions

Finding 2024-032 CCDF Cluster, ALN 93.575 and 93.596 - MWBC Child Care System User Access Management Views MiLEAP agrees with the finding. Planned Corrective Action The Michigan Workforce Background Check (MWBC) Child Care System is used to conduct and record the results of criminal history checks...

Finding 2024-032 CCDF Cluster, ALN 93.575 and 93.596 - MWBC Child Care System User Access Management Views MiLEAP agrees with the finding. Planned Corrective Action The Michigan Workforce Background Check (MWBC) Child Care System is used to conduct and record the results of criminal history checks for child care providers and is comprised of multiple modules, including the Consultant Portal and Analyst Portal. Each portal serves distinct functions, carrying varying levels of access to background check information and functionality. MiLEAP acknowledges that internal controls should more explicitly require module-specific documentation. To address this, MiLEAP has reinforced its access control procedures to ensure the Child Care Background Check (CCBC) Access and Security Agreement directs that access requests be sent to the manager of the CCBC unit and explicitly documents the specific portals being requested. The CCBC unit manager is responsible for reviewing and granting access to both the Analyst and Consultant portals based on the user’s role and job duties. MiLEAP has reinforced this policy as of May 2024 with appropriate staff to ensure compliance and improve documentation for each portal. Anticipated Completion Date Completed Responsible Individual(s) Jacob Poynter, MiLEAP Monica Sturdivant, MiLEAP

View Audit 360209

Finding 567688 (2024-022)

Significant Deficiency 2024

State of Michigan

MI

Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303

Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Service...

Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Services Division, and Bureau of Development-Design Division will collaborate and provide oversight to ensure that user access for the American Association of State Highway and Transportation Officials software (AASHTOWare) Preconstruction and Construction & Materials modules is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process, which will be facilitated by the designated System Security Administrators, and access will be modified or removed, as appropriate, prior to the end of each six-month period for privileged users and annually for all other users. Anticipated Completion Date January 1, 2026 Responsible Individual(s) Mark Shulick, MDOT Dan Burns, MDOT Kristin Schuster, MDOT Dee Parker, MDOT Lindsey Renner, MDOT Jason Gutting, MDOT Kyle Nelson, MDOT Andy Esch, MDOT

View Audit 360209

Finding 567608 (2024-001)

Material Weakness 2024

The Housing Authority of the City of Aiken, South Carolina

SC

Questioned Costs Matching / Level of Effort / Earmarking

2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housi...

2024-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed, Unallowed The Authority has developed procedures to ensure that restricted funds are repaid to the Low Rent Program and to ensure that further restricted funds are not advanced. Upon notification from the Department of Housing and Urban Development to cease and desist of the Authority’s cost sharing agreement, the Authority immediately discontinued the advancement of funds to other programs operated by the Authority. Current management is actively pursuing collection efforts and understands these federal guidelines. Person Responsible for Correction of Finding: Chanosha Lawton, Executive Director Projected Completion Date: June 30, 2025

View Audit 360162 Questioned Costs: $1

Finding 567592 (2024-002)

Significant Deficiency 2024

Alliance Apartments Housing Development Fund Co., Inc.

NY

Cash Management HUD Housing Programs Significant Deficiency

We have requested HUD approval to delay reimbursement of the reserves pending receipt of Budget Based Rent increase. We anticipate that this will be approved.

View Audit 360130

Finding 567564 (2024-003)

Material Weakness 2024

City of New Haven

CT

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

Finding 2024-003: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Coronavirus State and Local Fiscal Recovery Funds Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principl...

Finding 2024-003: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Coronavirus State and Local Fiscal Recovery Funds Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. While the City has a formal policy requiring the purchasing department to perform verification of suspension or debarment over vendors that the City makes contracts with federally funded projects, it does not maintain formal documentation that this procedure occurred. Corrective Actions Taken: 1. Develop Standard Documentation: Create a standardized verification form or checklist for suspension and debarment checks. Include fields for date, method of verification (e.g., SAM.gov search), name of reviewer, and signature. 2. Integrate into Procurement Workflow: Require completion and attachment of the verification form to all federally funded purchase orders and contracts before approval. Embed verification as a required step in MUNIS or other procurement software workflows, if possible. 3. Staff Training: Provide refresher training for purchasing and finance staff on federal compliance requirements, including suspension and debarment procedures. Emphasize the importance of documentation for audit and compliance purposes. Contact: Malinda Figueroa, Purchasing Director, Anticipated Completion Date: December 2025

View Audit 360119

Finding 567562 (2024-004)

Material Weakness 2024

City of New Haven

CT

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

Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principle...

Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. Without documented evidence verifying whether the City was following its policy, the City could not provide evidence of this control being completed for federally funded projects. There were no standard forms or templates that were used to document verification that parties are not suspended or debarred. Corrective Actions Taken: 1. Establish Documentation Protocols: The City is implementing standard templates and procedures for verifying suspension and debarment status, including documentation requirements. 2. System Integration and Workflow Updates: These procedures will be integrated into procurement workflows and reviewed regularly to ensure consistency across all federally funded contracts. 3. Monitoring and Oversight: A designated staff member will perform periodic reviews to confirm verification procedures are being followed and properly documented. Contact: Malinda Figueroa, Purchasing Director, Anticipated Completion Date: December 2025

View Audit 360119

Finding 567399 (2024-007)

Material Weakness 2024

Washington Parks Academy

MI

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

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We have brought on a State and Federal Grants Consultant to ensure all required grant related paperwork is completed and saved in a shared location with the Finance Team.

View Audit 360089

Finding 567398 (2024-006)

Material Weakness 2024

Washington Parks Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.501 § 200.512 § 200.514

The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an issue in the future.

View Audit 360089

Finding 567397 (2024-005)

Material Weakness 2024

Washington Parks Academy

MI

Subrecipient Monitoring Material Weakness Reporting § 200.303

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We will ensure all reporting is filed on a timely basis.

View Audit 360089

Finding 567396 (2024-004)

Material Weakness 2024

Washington Parks Academy

MI

Cash Management Subrecipient Monitoring Material Weakness § 200.303

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...

Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.

View Audit 360089

Finding 567384 (2024-001)

Significant Deficiency 2024

City of Dallas, Texas

TX

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.305 § 200.516

Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Part...

Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Party: Cynthia Rogers-Ellickson, Director – Housing & Community Development Planned Implementation Date: June 13, 2025

View Audit 360057 Questioned Costs: $1

Finding 567372 (2024-002)

Significant Deficiency 2024

National Federal of Families for Children's Mental Health

MD

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

Finding 2024-002 – Allowable costs – payroll Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization charged payroll costs to the federal award programs using a set percentage based on budget and not based on employee’s actual time or effort amongst various programs. Recomm...

Finding 2024-002 – Allowable costs – payroll Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization charged payroll costs to the federal award programs using a set percentage based on budget and not based on employee’s actual time or effort amongst various programs. Recommendation: We recommend the Organization make changes overall its timekeeping processes to ensure that payroll costs accurately reflect the work performed and if budget estimates are utilized, that they are reconciled and trued up on a consistent basis. Action Taken: NFFCMH has made changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed. The Organization is acting upon different guidance it has received, and as of the date this audit is released, the contract this finding addresses is currently scheduled to end on 08/30/2025. NFFCMH will continue our current practice through the end of this same contract, and we will review any potential change to same upon renewal or extension of this contract.

View Audit 360032

Finding 567371 (2024-001)

Significant Deficiency 2024

National Federal of Families for Children's Mental Health

MD

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

Finding 2024-001 – Procurement, suspension and debarment Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization contracted with several vendors for products and services who were paid more than $25,000. There was no evidence documenting that these vendors were checked for ...

Finding 2024-001 – Procurement, suspension and debarment Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization contracted with several vendors for products and services who were paid more than $25,000. There was no evidence documenting that these vendors were checked for suspension and debarment prior to payment. Recommendation: We recommend the Organization perform and document each verification on vendors over $25,000 prior to funds being disbursed. An alternative would be for the standard contract to address suspension and debarment and obtain the certification from the vendors at the time the contract is executed. Action Taken: NFFCMH now performs and documents verification on all vendors and subcontractors, through one of the following: 1) checking SAM exclusions; 2) collecting a certification from that person; or 3) adding a clause or condition to the covered transaction with that person. This practice has been implemented prior to the completion of the FY2024 Audit.

View Audit 360032

Finding 567123 (2024-008)

Significant Deficiency 2024

Cultivate Culinary School and Catering

IN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.214

Finding Reference Number: 2024-008 – COVID-19 - Coronavirus State and Local Recovery Funds. Compliance Requirement: Internal Control noncompliance - Procurement, Suspension, and Debarment. Name of Contact Person: Jim Conklin. Views of Responsible Officials: Management acknowledges the finding and un...

Finding Reference Number: 2024-008 – COVID-19 - Coronavirus State and Local Recovery Funds. Compliance Requirement: Internal Control noncompliance - Procurement, Suspension, and Debarment. Name of Contact Person: Jim Conklin. Views of Responsible Officials: Management acknowledges the finding and understands the need to perform a review of vendors paid using federal grant funds to determine if they are suspended or debarred. Planned Corrective Action: The Organization will provide training to staff involved in procurement to search the federal government website to determine if vendors selected are suspended or debarred. Documentation of this determination will be retained and reviewed by a member of management to evidence internal control over this procedure. Anticipated Completion Date: 6/30/2025.

View Audit 359998

Finding 567097 (2024-002)

Significant Deficiency 2024

Anoka County

MN

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2024-002 Finding Title: Suspension and Debarment Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lindsey Felgate – Senior Manager, Procurement Corrective Action Planned: ...

Finding Number: 2024-002 Finding Title: Suspension and Debarment Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lindsey Felgate – Senior Manager, Procurement Corrective Action Planned: The Procurement Unit will continue to educate county users on required policy & procedures. This would include a refresh to our new stand-alone procurement policy, a new procedure manual explaining in detail how to procure, and supplemental documents including forms and checklists to aid in compliance. We are upgrading SharePoint (internal website) to aid in sharing procurement information. We will continue to educate on process documentation including the federal guidance listed in Title 2 U.S. Code of Federal Regulations. The County has purchased a finance/procurement system set to go live in 1/2026. The system will manage the purchase order process and we will continue to find a procurement solution for all other procurement activities. These plans will assist by moving the County from a manual environment to a more structured and standardized environment for procurement activities. Anticipated Completion Date: • Policy – 2025, current summer action • Procedures & Supplemental documents (how to’s, forms, checklists) – initial draft end of 2025 with enhancements in 2026 • SharePoint Site Refresh – year end 2025

View Audit 359961

Finding 567094 (2024-002)

Significant Deficiency 2024

Yankton Transit, Inc.

SD

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Significant Deficiency § 200.313

Yankton Transit will become familiar with the requirements of CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures. Currently, we have changed the debit cards to credit cards for proper approval and complete support for t...

Yankton Transit will become familiar with the requirements of CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures. Currently, we have changed the debit cards to credit cards for proper approval and complete support for the transactions that occur monthly.

View Audit 359960

Finding 567052 (2024-001)

Material Weakness 2024

Community Foundation of Northwest Indiana, Inc.

IN

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

Finding 2024-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Grantor: United States Department of Homeland Security Assistance Listing No.: Assistance Listing 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disas...

Finding 2024-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Grantor: United States Department of Homeland Security Assistance Listing No.: Assistance Listing 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Indiana Department of Homeland Security Federal Award Period of Performance: March 1, 2020 – May 11, 2023 A material weakness was identified related to internal controls over payroll expenses charged to FEMA funds, subject to the Uniform Guidance (UG) audit. This guidance requires internal controls to comply with the terms of the federal award as well as with the "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control—Integrated Framework" issued by COSO. The finding was a compliance matter and did not result in any questioned costs. Community Foundation of Northwest Indiana, Inc. and Subsidiaries (CFNI) acknowledges the finding related to the lack of documented review and approval of all timecards for payroll expenses charged to federally funded programs. In line with industry standards, CFNI prioritizes timely payroll processing and does not delay payroll for outstanding timecard approvals. While this is not a recurring issue and did not result in any questioned costs, CFNI recognizes the importance of ensuring compliance with all federal requirements. To address this finding and prevent recurrence, CFNI is implementing a comprehensive policy that mandates timely review and approval of all timecards associated with payroll expenses charged to federal grants. Additionally, CFNI is establishing a formal process to monitor adherence to this policy, including regular audits and detailed documentation of the review process. CFNI is committed to strengthening internal controls, improving oversight, and ensuring full compliance with federal grant requirements. Responsible Official: Pamela Pokropinski, VP Finance Status of finding: Completion expected June 2025

View Audit 359944

Finding 567014 (2024-001)

Material Weakness 2024

City of Panama City Beach, Florida

FL

Subrecipient Monitoring Material Weakness Reporting § 200.303

City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal con...

City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal controls. While the report was prepared with diligence and care, we recognize that the absence of documented independent review poses a risk for potential errors and noncompliance with federal requirements. To address this issue, the City has established a formal process to ensure that future reports undergo an independent review before submission. A qualified staff member who is not involved in preparing the report will conduct the review, and both the preparer and the reviewer will sign and date the report to provide evidence of oversight. This documentation will be retained in the grant file for compliance and audit purposes. Staff involved in the reporting process have been informed of these new procedures to ensure consistency moving forward. The revised procedures have been adopted and will be applied to the next reporting cycle. Documentation of the review process will be retained and made available for future audits. The City is committed to maintaining compliance with all applicable federal regulations and improving internal controls to ensure the integrity and accuracy of all grant-related reporting. Anticipated Completion Date: June 2025 Responsible Contact Person: Debra Gibson

View Audit 359923

Finding 567004 (2024-001)

Significant Deficiency 2024

Greater Seacoast Community Health

NH

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordan...

Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Individual(s) Responsible for Corrective Action: Kimberly Garca, Director of Patient Accounts Planned Corrective Action: 1. Complete Q1 2025: Complete internal audit/monitoring for January, February and March. 2. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 3. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences. This ensures continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Anticipated Completion Date: • Corrective Action #1 has been completed as of 4/28/2025. • Corrective Action #2 has been completed as of 5/5/2025. • Corrective Action #3 will be completed by August 2025.

View Audit 359871

Corrective Action Plans

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