Corrective Action Plans

Finding 566850 (2024-008)

Material Weakness 2024

MO

Subrecipient Monitoring Special Tests & Provisions Material Weakness

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and t...

Finding 2024-008 Personnel Responsible for Corrective Action: Chief Information Officer - Vacant Anticipated Completion Date: August 31, 2025 Corrective Action Plan: Harris-Stowe State University acknowledges the audit finding regarding noncompliance with the Gramm-Leach-Bliley Act (GLBA) and the FTC Safeguards Rule. In response, the University has collaborated with Omega Technical Solutions and ileap Group to execute a comprehensive cybersecurity compliance and modernization initiative. As of the audit period close, over 90% of related deficiencies have been remediated. Specific corrective actions taken or underway include: 1. Written Information Security Program (WISP): A formal WISP has been developed and implemented. It outlines oversight structures, risk management strategies, testing protocols, and required safeguards in alignment with 16 CFR 314.4. 2. Risk Assessment: A comprehensive risk scorecard was created. All Active Directory accounts were reviewed and flagged for deactivation or role reassignment as appropriate. 3. Access and Encryption Controls: Encryption is now deployed across all active endpoints. Logical access control and encryption policies have been adopted and published. Multi-factor authentication (MFA) is enforced for all systems handling student data. 4. Account Management and Role-Based Access: RBAC policies have been established and account provisioning is now formally documented and managed. 5. Retention, Change Management, and Training: A written data retention policy and formal change management procedures are now in place. An onboarding cybersecurity training program has been developed, with full implementation scheduled by August 31, 2025. 6. Legacy Server Risk Mitigation: One legacy Microsoft 2008 server has failed and is decommissioned. The remaining server is isolated, monitored with NIST- and Microsoft Sentinel-aligned tools, and pending full replacement as part of the upcoming infrastructure upgrade. 7. Ongoing Monitoring and Vendor Oversight: TCPM-aligned monitoring practices and vendor oversight protocols are now active and included in the WISP framework. The University’s IT Security SharePoint site houses all related documentation and is structured to support transparency, audit readiness, and continued compliance oversight.

View Audit 359750

Finding 566112 (2024-005)

Material Weakness 2024

Housing Authority of the City of Alliance, Nebraska

NE

HUD Housing Programs Material Weakness Reporting

The Alliance Housing Authority agrees with finding. Because of the transfer of the Rosewood Estates property, the financials were not available to the fee accountant in time to submit with the AHA REAC submission. The AHA understands that the submission is due within 60 days after the FYE and also ...

The Alliance Housing Authority agrees with finding. Because of the transfer of the Rosewood Estates property, the financials were not available to the fee accountant in time to submit with the AHA REAC submission. The AHA understands that the submission is due within 60 days after the FYE and also understands there is a 15-day grace period after the 60 days in order to submit. Rather than submitting late the REAC submission was submitted within this time frame without the Rosewood information. The AHA is now forwarding Rosewood information from the management company to the fee accountant monthly and this should remedy this finding in order to properly submit for the 2025 fiscal year.

View Audit 359703

Finding 566042 (2024-001)

Material Weakness 2024

Southern Nevada Regional Housing Authority

NV

Questioned Costs HUD Housing Programs Subrecipient Monitoring

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training A...

Finding 2024- 001: Housing Choice Voucher Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance and Material Weakness Corrective Action Plan: Training: To reinforce compliance and ensure consistent adherence to policies a specialized team including a Compliance & Training Administrator, a Trainer, and two Senior Occupancy Specialists-has been established to oversee all Housing Choice Voucher (HCV) program training and compliance. This team is responsible for: ■ New hire training to ensure foundational competency. • Refresher trainings to address knowledge gaps and reinforce standards. • Policy & procedure update trainings to keep staff informed of changes. Quality Control: We conduct 100% quality control on all new hires', completed action files and 100% quality control on all contract files. Twenty-five percent (25%) of all Non-provisional employees work product is quality controlled by the compliance team. Department Structure: The entire leadership team completed Nan McKay's HOTMA training to ensure full alignment with the latest Housing Opportunity Through Modernization Act {HOTMA) requirements. This top-down approach guarantees that policy Interpretations and training materials are consistent and up to date. To ensure all required documents are properly retained and accessible, the agency has expedited the transition to a fully digital file system. This will Include standardized naming conventions, centralized storage with access controls, and a documented retention protocol to prevent future discrepancies. Additionally, any staff that falls below the 80 % success rate will be required to actively engage in all mandated trainings and utilize the compliance team as a resource for clarification. Furthermore, staff requiring further reinforcement will be promptly addressed through one-on one coaching or additional training sessions with their immediate supervisor. Anticipated Completion Date: The current staff is attending monthly trainings on the Administrative Plan, best practices and HOTMA policy changes. We anticipate completion of the plan by 12/31/2025. Person Responsible: Ms. Rhonda Jackson, Housing Program Manager II, Ms. Malandria Watson, Housing Program Manager I, -and Ebony Bell, Compliance and Training Administrator will be responsible for reviewing the Quality Control Report and error ratios monthly.

View Audit 359697 Questioned Costs: $1

Finding 566026 (2024-002)

Material Weakness 2024

Lane Community College

OR

Student Financial Aid Reporting Subrecipient Monitoring

2024-002 – Special Tests and Provisions - Enrollment Reporting – Material Weakness in Internal Controls over Compliance Student Financial Assistance Cluster Department of Education Federal Assistance Listing Number: 84.063, 84.268 Federal Program Name: Federal Pell Grant Program, Federal Direct Stu...

2024-002 – Special Tests and Provisions - Enrollment Reporting – Material Weakness in Internal Controls over Compliance Student Financial Assistance Cluster Department of Education Federal Assistance Listing Number: 84.063, 84.268 Federal Program Name: Federal Pell Grant Program, Federal Direct Student Loans Federal Award Number: P063P230357, P268K230357 Award Year: 2023-24 Criteria: The National Student Loan Data System (NSLDS) is the Department of Education’s (ED) centralized database for students’ enrollment information under the Pell Grant and the Direct Loan and Federal Family Education Loan programs. Uniform guidance requires institutions to have internal controls in place to ensure attendance changes for students are reported to NSLDS within at least 60 days of when the student attendance change occurs. It is the College’s responsibility to update students' enrollment information timely and accurately as outlined in 34 CFR § 685.309. Condition/context: The auditors selected a sample of 34 students out of a population of 1,454 who had received Federal aid and had withdrawn or graduated from the College during the 2023-2024 fiscal year. The auditors compared the withdrawal or graduation date per the College’s records to NSLDS. The auditors noted eight students were not reported to NSLDS within the 60-day requirement. In addition, the auditors identified ten students who graduated but were not reported as graduated to NSLDS. Corrective Action: LCC reports enrollment to the National Student Clearinghouse: in the second, sixth and the tenth week of each standard term. There is an error report that the Clearinghouse returns with discrepancies in enrollment status which we respond to and correct within five business days. Once all errors are resolved and the report is accepted the NSC will post the data and report to NSLDS. Lane is an open access institution and therefore does not have a formal withdrawal policy. Two weeks after the end of each term, Lane sends the enrollment report and the “degree verify” extract to NSC. We are in the process of reviewing our NSC reporting strategies and including additional staff who will be supporting the process. We are reviewing NSC reporting times to ensure that we are reporting often enough to meet the required 60 day timeline for NSLDS. We are considering moving the enrollment and degree verify extract to a 30 day reporting period to meet the 60 day timeline. Phase 1: Issue an off cycle report to the NSC by June 6th, which is our next anticipated enrollment reporting cycle (week ten). We will send both the enrollment report and the “degree verify” extract to catch any updates to graduation information that may have changed since our last end of term report. Phase 2: Review updates to NSC processes that were issued through Banner and Ellucian and revise the “degree verify” process to capture regular graduation or withdrawal updates outside our standard reporting window. Unless it is discovered that the 30 day cycle does not meet the requirements of the reporting cycle, we will update our processes to - at a minimum - report every 30 days or in alignment with the weeks two, six and ten current enrollment report to the NSC. Additionally, the students noted in the finding will be reviewed to address any potential anomalies with reporting and to identify the cause of why these were not updated. This will be another consideration during the assessment for any updates to our reporting cycles. Following spring term, we will report graduated and withdrawn students, as is our current practice and after student degree awarding is complete. Name of Contact Person Responsible for Corrective Action: Dawn Whiting Anticipated Completion Date for the Corrective Action: A review process of 90 days should result in refined practices and an implementation of those practices to meet required reporting. All reporting changes will be finalized and followed by Aug 21, 2025.

View Audit 359666

Finding 566008 (2024-001)

Material Weakness 2024

Palm Beach County Housing Authority

FL

Questioned Costs HUD Housing Programs Subrecipient Monitoring

2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement intern...

2024-001 – Eligibility Housing Voucher Cluster – Assistance Listing 14.871 and 14.879 Recommendation: We recommend that management conduct training for program staff on eligibility documentation requirements and program rules. Additionally, we recommend that the Housing Authority implement internal audits of tenant files to proactively identify and correct documentation issues. A monitoring protocol should also be established to ensure ongoing compliance and to prevent the recurrence of documentation deficiencies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All current PBCHA staff responsible for eligibility determinations have received HCV rent calculation training through Nan McKay as of March 21, 2025. The PBCHA will continue to conduct training for program staff on eligibility documentation requirements and program rules to reinforce compliance standards. Through the implementation of intakes, interims and annual recertifications utilizing Yardi’s online workflows, the PBCHA expects to see increased improvement through automated application and documentation processes. The PBCHA will utilize available dashboards, internal audits and formal monitoring protocols to ensure continued compliance and to minimize the risk of recurring deficiencies. Name(s) of the contact person(s) responsible for corrective action: Yvette Bembry Planned completion date for corrective action plan: December 31, 2025

View Audit 359660 Questioned Costs: $1

Finding 566005 (2024-002)

Material Weakness 2024

Beaumont Senior Citizens Housing, Inc.

TX

HUD Housing Programs Material Weakness Matching / Level of Effort / Earmarking

CORRECTIVE ACTION PLAN Name and Number of the Project: Beaumont Senior Citizens Housing, Inc. FHA/CONTRACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2024 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations...

CORRECTIVE ACTION PLAN Name and Number of the Project: Beaumont Senior Citizens Housing, Inc. FHA/CONTRACT NO. 114-11227 Audit Firm: M Group, LLP Audit Period: The year ended June 30, 2024 Compliance Review COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2024-002: Section 8 Housing Assistance Payments Program, Assistance Listing: 14.195 and Mortgage Insurance Section 223(f) Insured Loan, Assistance Listing: 14.155 CORRECTIVE ACTION TO BE COMPLETED: The Organization intends to apply for reinstatement of tax-exempt status. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

View Audit 359651

Finding 565997 (2024-002)

Material Weakness 2024

Independent Living Place, Inc.

TX

Questioned Costs HUD Housing Programs Material Weakness

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2024 Compliance Review: COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors...

CORRECTIVE ACTION PLAN Name and Number of the Project: INDEPENDENT LIVING PLACE, INC. No. 115-EH115 Audit Firm: M Group, LLP Audit Period: The year ended September 30, 2024 Compliance Review: COMMENTS ON FINDINGS AND RECOMMENDATIONS We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. ACTIONS TAKEN FINDING #2024-002: Section 202 Supportive Housing for the Disabled, Assistance Listing 14.157 CORRECTIVE ACTION TO BE COMPLETED: The Organization intends to apply for reinstatement of tax-exempt status. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Mr. Stewart Grounds, Chief Financial Officer of Arnold-Grounds Apartment Management & Affordable Housing Specialists, LLC.

View Audit 359648 Questioned Costs: $1

Finding 565994 (2024-002)

Material Weakness 2024

Washington Local School District

OH

Subrecipient Monitoring Reporting Material Weakness § 200.328 § 200.330

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Require training for all staff involved in preparing, reviewing, or...

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Require training for all staff involved in preparing, reviewing, or certifying federal grant reports, prior to beginning any work. Work with a Financial Program Manager at the Office of Budget and Management (Neal Bucklew was the district’s contact on this particular grant) to ensure that all activity reports are submitted correctly and received on time.

View Audit 359647

Finding 565991 (2024-002)

Material Weakness 2024

Central Virginia Legal Aid Society, Inc.

VA

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

Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthl...

Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthly through reports run in the case management system designed to identify cases where LSC or the Organization’s policies were not met. The second will be a review by the Managing Director of each of the Organization’s practice area groups where the case was closed to ensure compliance with LSC and the Organization’s requirements. In addition, training of new employees as part of their onboarding, and an annual training course for all of the Organization’s staff, will be held on LSC and the Organization’s case acceptance and reporting requirements and the use of tools, such as case management reports and checklists, to ensure compliance. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025

View Audit 359640

Finding 565990 (2024-001)

Material Weakness 2024

Central Virginia Legal Aid Society, Inc.

VA

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

Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthl...

Corrective Action Taken or Planned: The Organization will immediately implement a more formal review process for review of citizenship attestations and asset levels to ensure compliance before cases are reported to LSC. This review process will consist of two checks. The first will be done monthly through reports run in the case management system designed to identify cases where LSC or the Organization’s policies were not met. The second will be a review by the Managing Director of each of the Organization’s practice area groups where the case was closed to ensure compliance with LSC and the Organization’s requirements. In addition, training of new employees as part of their onboarding, and an annual training course for all of the Organization’s staff, will be held on LSC and the Organization’s case acceptance and reporting requirements and the use of tools, such as case management reports and checklists, to ensure compliance. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: April 30, 2025

View Audit 359640

Finding 565770 (2024-001)

Material Weakness 2024

Boys & Girls Club of Huntington County, Inc.

IN

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.430

2024-001 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Material Weakness in Internal Control Over Compliance and Noncompliance...., Inadequate Payroll Documentation B. Allowable Costs/Cost Principles Recommendation: The Auditors recommend that management ensure all ...

2024-001 Twenty-First Century Community Learning Centers - Assistance Listing No. 84.287 Material Weakness in Internal Control Over Compliance and Noncompliance...., Inadequate Payroll Documentation B. Allowable Costs/Cost Principles Recommendation: The Auditors recommend that management ensure all employee timecards are signed or electronically certified by the employee in a timely manner. The Auditors also recommend a process be implemented to reconcile time charge to federal award to underlying payroll report. Internal controls should be reinforced to verify that no payroll costs are charged to federal programs without appropriate documentation and approval. Action Taken : We agree with the recommendation and updated our written policy in 2024 . The policy was reviewed by the Finance Committee and approved by the full Board of Directors in December 2024.

View Audit 359460 Questioned Costs: $1

Finding 565724 (2024-002)

Material Weakness 2024

School District of Cudahy

WI

Material Weakness Reporting Internal Control / Segregation of Duties

Plan: The District acknowledges the finding and will review the bank reconciliation process and procedures. Anticipated Date of Completion: The District will immediately implement yearly review of the fiscal closing process.

View Audit 359434

Finding 565665 (2024-002)

Material Weakness 2024

Community Action Partnership of North Dakota Inc.

ND

Subrecipient Monitoring Material Weakness

2024-002 - Subrecipient Montoring Controls - CSBG Person responsible for corrective action - Andrea Olson, Executive Director Responsible officials response - Management is in agreement with this finding. Corrective action planned - CAPND has a comprehensive monitoring plan to monitor all grant supp...

2024-002 - Subrecipient Montoring Controls - CSBG Person responsible for corrective action - Andrea Olson, Executive Director Responsible officials response - Management is in agreement with this finding. Corrective action planned - CAPND has a comprehensive monitoring plan to monitor all grant supported activities in accordance with program rules relative to CSBG program including rules established by the program, those established by CAPND, and by 2 CFR Part 200. The plan was not fully adhered to during the 2023 but had been for 2024. Planned implementation date of corrective action – July 1, 2024

View Audit 359346

Finding 565662 (2024-003)

Material Weakness 2024

Community Action Partnership of North Dakota Inc.

ND

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

2024-003 Subrecipient Monitoring and Allowable Costs – Material Weakness Person responsible for corrective action – Andrea Olson, Executive Director Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported activities in accordance with program rules relativ...

2024-003 Subrecipient Monitoring and Allowable Costs – Material Weakness Person responsible for corrective action – Andrea Olson, Executive Director Corrective action planned – CAPND has a comprehensive monitoring plan to monitor all grantsupported activities in accordance with program rules relative to SSVF program including rules established by the VA, those established by CAPND, and by 2CFR Part 200. Planned implementation date of corrective action – June 18, 2025

View Audit 359346

Finding 565485 (2024-038)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY 2024-038 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend the Department review and enhanc...

MASSACHUSETTS EMERGENCY MANAGEMENT AGENCY 2024-038 Disaster Grants – Public Assistance (Presidentially Declared Disasters), COVID-19 - Disaster Grants – Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend the Department review and enhance its procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: MEMA is recognizing the importance of documentation and internal controls. This current fiscal year an Internal Control Group was formed to review, create and overhaul what is needed or needed to be updated. The team primary stakeholders is made up of the CFO, Legal Counsel, Assistant Director for Recovery and Mitigation and Emergency Management Grants Supervisor. We are making the completion of updated Policies and Procedures a priority to address the findings such as the ones being pointed out as a critical piece to the success of the agency going forward. Name(s) of the contact person(s) responsible for corrective action: Randall Lui Planned completion date for corrective action plan: End of the Federal Fiscal Year 9/30/2025

View Audit 359283

Finding 565469 (2024-032)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-032 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department review and enhance procedures and internal controls to ensure that, at the conclusion of fraud investigations, decision letters are issued promptly and tha...

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-032 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department review and enhance procedures and internal controls to ensure that, at the conclusion of fraud investigations, decision letters are issued promptly and that repayments are received timely. Action taken in response to finding: EEC is taking steps to strengthen internal controls related to the fraud investigation process by reviewing and updating procedures to ensure timely issuance of decision letters at the conclusion of investigations. As part of this effort, EEC will assess current response timelines to identify delays and implement improvements. This includes establishing benchmarks for the timely issuance of decision letters and the initiation of repayment processes. In addition, we are implementing enhanced tracking systems to monitor key milestones and ensure timely follow-up. Staff training will be conducted to reinforce procedural expectations around timelines and documentation. These combined efforts will promote consistency, accountability, and improved timeliness. Name(s) of the contact person(s) responsible for corrective action: Tyreese Nicolas, Deputy Commissioner for Family Access and Engagement Planned completion date for corrective action plan: October 1, 2025

View Audit 359283

Finding 565467 (2024-031)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-031 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the mont...

DEPARTMENT OF EARLY EDUCATION AND CARE 2024-031 CCDF Cluster - Assistance Listing No. 93.575, 93.596 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: EEC developed and implemented new policies and procedures that detail the FFATA reporting requirements, notification process, and control environment, including the data sources, in September of 2022. EEC did not implement the procedures necessary to ensure the report is submitted to SAM.gov in a timely manner as required. Applicable Accounting, Contracts, and Budget staff will be trained on these policies and procedures. Name(s) of the contact person(s) responsible for corrective action: Eric Hansson, Chief Financial Officer/CFO and Acting Chief Operating Officer/COO Planned completion date for corrective action plan: October 1, 2025

View Audit 359283

Finding 565455 (2024-021)

Material Weakness 2024

Commonwealth of Massachusetts

MA

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

DEPARTMENT OF PUBLIC HEALTH 2024-021 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend that the Department review and enhance its procedures and internal co...

DEPARTMENT OF PUBLIC HEALTH 2024-021 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend that the Department review and enhance its procedures and internal controls to ensure that performance reports are submitted timely and that the review and approval process of financial and performance reports is documented prior to submission. Action taken in response to finding: Fiscal reporting will consist of email communication from the Director of Administration and Finance to the Project Director requesting the Project Director to review both the quarterly report in the ELC’s CAMP portal and the attached spreadsheet backup attached to the email communication that supports the financial data in ELC’s CAMP portal. The Project Director will review the spreadsheet and financial data in ELC CAMP. If the Project Director, approves, the PD will email the Director of Administration and Finance stating that she has reviewed and approved the data in the spreadsheet and in the ELC CAMP portal. If the PD does not approve, the PD will communicate this through email to the Director of Administration and Finance with what the issues are and ask the Director of Administration and Finance to correct and resubmit the information to PD. The same process as noted above will be followed until it is approved by the PD. Programmatic performance reporting with be entered into the ELC CAMP Portal by ELC multiple programmatic leads for various ELC sections. Once completed, the multiple programmatic leads will email the Project Director to review. The Project Director will review the programmatic data in the ELC CAMP portal. The Project Director will send multiple programmatic leads and email with her approval and ask them to submit his/her section in ELC CAMP. If the Project Director finds errors, she will email the programmatic lead(s) identifying the error and ask the programmatic lead(s) to correct. The same process noted above would continue until the Project Director approves the programmatic performance report. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS ; Natalie Morgenstern, Project Director, ELC leads for various ELC sections for performance reports (multiple staff) Planned completion date for corrective action plan: 8/31/2025

View Audit 359283

Finding 565453 (2024-020)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure t...

DEPARTMENT OF PUBLIC HEALTH 2024-020 Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323 Recommendation: We recommend the Department establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Epidemiology and Laboratory Capacity for Infectious Diseases COVID-19 – Epidemiology and Laboratory Capacity for Infectious Diseases - Assistance Listing No. 93.323, to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565451 (2024-019)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedu...

DEPARTMENT OF PUBLIC HEALTH 2024-019 Immunization Cooperative Agreements, COVID-19 - Immunization Cooperative Agreements - Assistance Listing No. 93.268 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior audit. It should establish procedures and internal controls to ensure that all required subawards are reported timely and accurately to the FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: The Bureau of Infectious Disease and Laboratory Sciences (BIDLS) will put in place starting August 1, 2025 a process to review obligations for subawards under Immunization, Assistance Listing No. 93.268 to identify subawards that fall under the rules set forth by Federal Funding Accountability and Transparency Act (FFATA) and report the appropriate obligations to FSRS according to the above-mentioned recommendations. Name(s) of the contact person(s) responsible for corrective action: Cheryl Bernard-Dort, Director of Administration and Finance, BIDLS Planned completion date for corrective action plan: 9/30/25

View Audit 359283

Finding 565442 (2024-016)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the...

EXECUTIVE OFFICE OF ELDER AFFAIRS 2024-016 Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to FSRS no later than the end of the month following the month of issuance of each subaward. Action taken in response to finding: AGE has developed a form to attach to all relevant contracts to capture required reporting requirements and will implement a calendar of reporting deadlines to the AGE internal control plan, specifically the section regarding federal grants management. Name(s) of the contact person(s) responsible for corrective action: Sheila Tunney, CFO Planned completion date for corrective action plan: 9/30/2025

View Audit 359283

Finding 565427 (2024-011)

Material Weakness 2024

Commonwealth of Massachusetts

MA

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

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that intern...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-011 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: This issue occurred during a period when the preparation and submission of the ETA 9130 reports were handled by a single staff member without peer review. The lack of internal checks and collaborative review contributed to the inaccuracies. With new management and restructured team now in place, we have implemented and strengthened review processes. Moving forward, ETA 9130 reports will be jointly reviewed by Finance and program staff before submission and certification. Supporting documentation will be cross-checked for accuracy and completeness, and all relevant files will be maintained in a centralized, shared folder to ensure transparency and accountability. This multi-layered review and documentation process will be incorporated into standard quarterly reporting procedures to prevent future discrepancies and ensure federal reporting integrity. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke, Vina Yung Planned completion date for corrective action plan: 8/30/2025

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Finding 565424 (2024-010)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to ...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-010 WIOA Cluster - Assistance Listing No. 17.258, 17.259, 17.278 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved and subsequently reported timely to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance has finalized a Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and efficiently. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

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Finding 565414 (2024-007)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Subrecipient Monitoring Material Weakness Reporting § 200.303

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submi...

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2024-007 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should implement procedures and internal controls to ensure that all required subawards are reviewed, approved, and subsequently timely submitted to FSRS no later than the end of the month following the month of issuance. Documentation of implemented controls should be readily available for auditors. Action taken in response to finding: EOLWD Finance needs to update the Standard Operating Procedure (SOP) to ensure compliance with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements. FFATA reporting as of FY 2025 has been transitioned to SAM.gov, providing a more streamlined and user-friendly platform for managing and tracking subaward reporting. To support timely submissions, a calendar reminder has been implemented to prompt monthly checks of reporting activity. The next phase of implementation will focus on expanding staff training to ensure more team members are equipped to complete FFATA reporting tasks accurately and by establishing a more accurate subaward report. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. Name(s) of the contact person(s) responsible for corrective action: Sarah Shannon, Ken Luke Planned completion date for corrective action plan: 9/30/2025

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Finding 565411 (2024-003)

Material Weakness 2024

Commonwealth of Massachusetts

MA

Special Tests & Provisions Procurement, Suspension & Debarment Eligibility § 200.303

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program require...

DEPARTMENT OF TRANSITIONAL ASSISTANCE 2024-003 SNAP Cluster - Assistance Listing No. 10.551, 10.561 Recommendation: We recommend the Department review and enhance procedures and controls to ensure that documentation for EBT reconciliations is maintained in accordance with the federal program requirements. Action taken in response to finding: Starting July 2025, the Accounting Director (or Deputy Accounting Director when hired) will sign and date the reconciliation documentation (and retain) when reviews are performed. The standard operating procedures will be clarified that preparer and reviewer typing their names and date within the reconciliation documentation is an acceptable form of sign-off upon completion of the reconciliations and reviews. Name(s) of the contact person(s) responsible for corrective action: Keivon Spencer, Director of Accounting | DTA Finance Planned completion date for corrective action plan: June 30, 2025 and forward – Sign and date reconciliation reviews October 30, 2025 – Standard operating procedures

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