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Corrective Action Plans

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City of Oak Hill
WV
Questioned Costs Reporting Internal Control / Segregation of Duties
2024-003 Uniform Guidance Audit Valerie Vaughn, 6/30/2026 Submission Deputy City Clerk - Office Manager Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facil...
2024-003 Uniform Guidance Audit Valerie Vaughn, 6/30/2026 Submission Deputy City Clerk - Office Manager Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission as set forth in the Uniform Guidance.
View Audit 365062
Finding 574757 (2024-003)
Material Weakness 2024
Corewell Health & Affiliates
MI
Equipment & Real Property Management Matching / Level of Effort / Earmarking Questioned Costs § 200.303
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Th...
Identification of the federal program: Federal Agency: U.S. Department of Homeland Security (DHS) Assistance Listing: 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: Michigan State Police Emergency Management and Homeland Security Division Pass-Through Award Number: 4494-DR-MI Pass-Through Award Period: 7/1/2022-4/30/2023 Summary of Finding: The Personal Protective Equipment (PPE) and other COVID related supplies were not used within the period of performance outlined within the project worksheet. There were three FEMA obligations during FY 2024. An overstatement of expenditures in one of the projects (project 10) was identified with an obligation amount of $6,732,507. The period of performance as specified within the project 10 application is July 2, 2022 to April 30, 2023 and $1,077,759 of costs were not used by April 30, 2023. The overstatement represents approximately 16% of the amounts reported in the project 10 application and 14% of the total FEMA obligations in FY 2024. The total federal expenditures for FEMA for FY 2024 were $7,795,530. Corrective Action Plan: Management agrees that a thorough review of the claim was not completed prior to submitting the Request for Reimbursement to the State of Michigan, thus causing a control deficiency. In the future management will perform, document, and sign off on a thorough claim review to validate that all final adjustments have been submitted prior to submitting the Request for Reimbursement to the State. Individuals responsible for corrective action: Brittany Kruse, Vice President Finance and Assistant Controller Cindy Brink, Director, System Accounting and Reporting. Timing of corrective action: September 1, 2025 and going forward.
View Audit 365058 Questioned Costs: $1
Finding 574741 (2024-004)
Significant Deficiency 2024
Southern Minnesota Regional Legal Services Inc.
MN
Questioned Costs Allowable Costs / Cost Principles
Management agrees with the auditor's findings. The Director of Litigation (Lisa Hollingsworth) will have the Regional Leaders remind their staff about the necessity of obtaining retainer agreements from clients in extended service cases.
Management agrees with the auditor's findings. The Director of Litigation (Lisa Hollingsworth) will have the Regional Leaders remind their staff about the necessity of obtaining retainer agreements from clients in extended service cases.
View Audit 365057
Finding 574740 (2024-003)
Significant Deficiency 2024
Southern Minnesota Regional Legal Services Inc.
MN
Questioned Costs Allowable Costs / Cost Principles
Management agrees with the auditor's findings and will take immediate action to revise the attorney fees allocation. The Director of Finance (Vannam Khen) will review and work directly with the Finance staff to ensure attorney fees are allocated properly.
Management agrees with the auditor's findings and will take immediate action to revise the attorney fees allocation. The Director of Finance (Vannam Khen) will review and work directly with the Finance staff to ensure attorney fees are allocated properly.
View Audit 365057
Finding 574739 (2024-002)
Significant Deficiency 2024
Southern Minnesota Regional Legal Services Inc.
MN
Questioned Costs Subrecipient Monitoring
Management agrees with the auditor's findings and has completed the revision of the Organization's accounting manual to align with the regulatory requirements. The Director of Finance (Vannam Khen) worked directly with the Organization's assigned Fiscal Compliance Analyst from Legal Services Corpora...
Management agrees with the auditor's findings and has completed the revision of the Organization's accounting manual to align with the regulatory requirements. The Director of Finance (Vannam Khen) worked directly with the Organization's assigned Fiscal Compliance Analyst from Legal Services Corporation {LSC) to ensure policies and procedures are aligned with LSC's Financial Guide. The Organization's revised accounting manual has been approved by the Finance and Audit Committee and is effective as of June 2, 2025.
View Audit 365057
Finding 574735 (2024-001)
Significant Deficiency 2024
Barnes County Housing Authority
ND
HUD Housing Programs Questioned Costs Significant Deficiency
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
Contact Person Jan Kamstra, Executive Director Corrective Action Plan The Authority will review its procedures over utility allowances to ensure a secondary review of the schedule is performed. Planned Completion Date for CAP Immediately
View Audit 365045
Finding 574732 (2024-001)
Significant Deficiency 2024
Early Learning Indiana, Inc.
IN
Questioned Costs Allowable Costs / Cost Principles § 200.430
2024-001 Head Start – Assistance Listing No. 93.600 Significant Deficiency in Internal Control Over Compliance and Noncompliance – Inadequate Payroll Review and Documentation B. Allowable Costs/Cost Principles Recommendation: The auditor recommended that management establish detective controls to ...
2024-001 Head Start – Assistance Listing No. 93.600 Significant Deficiency in Internal Control Over Compliance and Noncompliance – Inadequate Payroll Review and Documentation B. Allowable Costs/Cost Principles Recommendation: The auditor recommended that management establish detective controls to ensure payroll expenses are being charged consistent with established policies and approved allocations. Action Taken: We agree with the recommendation and portions of the plan were implemented in February 2024, while the remainder was implemented in July 2025. In January 2024, the ELI team reviewed team members and their respective salary allocations, specifically for the Early Head Start program. Allocations were documented and updated in Axiom, ELI’s payroll system of record. Those allocations were then updated in early February 2024 and regular meetings to review, document and update allocations as needed, have since been held on a consistent basis. The secondary piece, corrected in July 2025, was a system correction for allocation of PTO and Holiday pay, those were not being allocated to EHS consistent with the agreed upon allocations and not going to EHS as they should have been. This has been corrected in Axiom and the ELI accounting team will now perform regular reviews to confirm allocation in agreement with the agreed upon amounts. In addition, correcting entries for 2024 and 2025 will be made by August 31, 2025.
View Audit 365042 Questioned Costs: $1
Finding 574705 (2024-002)
Significant Deficiency 2024
City of West Allis
WI
HUD Housing Programs Questioned Costs Significant Deficiency
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the service...
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the services of McCright & Associates LLC, a reputable HQS servicing company, to assist with rent reasonableness requirements. McCright now conducts all rent reasonableness comparables for all new units and staff confirm that a copy is stored in the participant file. Staff believe that with the implementation of these procedures appropriate steps have been taken to address this concern
View Audit 364984
Finding 574704 (2024-001)
Significant Deficiency 2024
City of West Allis
WI
HUD Housing Programs Questioned Costs Eligibility
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
View Audit 364984
Finding 574699 (2024-001)
Material Weakness 2024
The Contingent
OR
Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.430
Management will continue to reinforce utilization of the time tracking system that was implemented in 2024. In addition, management will ensure that the timecards submitted by staff are reviewed and approved timely.
Management will continue to reinforce utilization of the time tracking system that was implemented in 2024. In addition, management will ensure that the timecards submitted by staff are reviewed and approved timely.
View Audit 364980 Questioned Costs: $1
Lancaster Village Consumer Housing Cooperative
IN
Questioned Costs HUD Housing Programs
Management will ensure that HUD issues Form HUD-9250 for all withdrawal requests, including one that addresses the additional $4,458 that was withdrawn from replacement reserves account.
Management will ensure that HUD issues Form HUD-9250 for all withdrawal requests, including one that addresses the additional $4,458 that was withdrawn from replacement reserves account.
View Audit 364928 Questioned Costs: $1
Finding 574643 (2024-004)
Significant Deficiency 2024
Saint Mary-of-the- Woods College
IN
Questioned Costs Eligibility Significant Deficiency
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
View Audit 364915
Finding 574641 (2024-001)
Significant Deficiency 2024
Friends of Family Health Center
CA
Special Tests & Provisions Questioned Costs Significant Deficiency
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selecte...
Condition Friends of Family Health Center lacked adequate controls over its sliding fee discount program to ensure patients received the correct discount. In testing patients receiving discounts under Friends of Family Health Center's sliding fee schedule, we noted that for 1 of 40 patients selected for testing Friends of Family Health Center incorrectly applied the discount or were put in the incorrect category based on income and family size. Response One error in calculating a patient’s income with 40 others is a minor 2.5% error margin. FOFHC will have a quarterly training course on how to properly use the various income level tables provided to the front office staff. Responsible Party Dawn Ta, CFO Estimated Completion Date December 31, 2025
View Audit 364910
Finding 574640 (2024-005)
Material Weakness 2024
Red Mesa Unified School District #27
AZ
Internal Control / Segregation of Duties Questioned Costs Material Weakness
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context...
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context: Documentation was not provided to support the number of federally connected students reported on the Impact Aid application. Corrective Action: The District will establish a process to ensure proper documentation is maintained to support the Impact Aid application. Planned completion date for corrective action plan: For the period ending August 31, 2025. Name of the contact person responsible for corrective action: Laticia John, Business Coordinator
View Audit 364909
Finding 574639 (2024-003)
Significant Deficiency 2024
Tazewell County, Illinois
IL
Procurement, Suspension & Debarment Questioned Costs Significant Deficiency
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all ...
Views of responsible officials and planned corrective action: Management has changed the process in place for grant expenditures where the expenditure does not go through the formal bidding process. This will ensure the County obtains attestation regarding federal suspension and debarment from all vendors working on projects funded by federal grant dollars.
View Audit 364907
Finding 574627 (2024-003)
Significant Deficiency 2024
Aurora Housing Authority
CO
Special Tests & Provisions Questioned Costs HUD Housing Programs
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
View Audit 364890
Finding 574624 (2024-002)
Significant Deficiency 2024
Aurora Housing Authority
CO
Questioned Costs Eligibility HUD Housing Programs
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
View Audit 364890
Finding 574616 (2024-003)
Material Weakness 2024
Southwestern Christian University, Inc.
OK
Questioned Costs Material Weakness
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, fami...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, families, and employees. We are committed to safeguarding sensitive data as part of our responsibility to operate with integrity and stewardship. To address these findings, SCU is working closely with our IT specialist in taking the following steps: a. Information Security Program: we are formalizing a written information security plan that meets the GLBA requirements, including risk assessment, safeguards, and monitoring. b. Designation of Coordinator: A qualified staff member has been designated to oversee GLBA compliance and ensure accountability in implementing safeguards. c. Employee training: Faculty and staff will be trained on data privacy, cybersecurity practices, and proper handling of sensitive information. d. Technical Safeguards: We will be enhancing systems for data encryption, access controls, and monitoring to reduce risks related to unauthorized access or disclosure. e. Ongoing review: Regular testing, audits, and updates will be conducted to ensure continuous improvement and adherence to GLBA standards. At Southwestern Christian University, we believe in protecting the personal information of our students and families is part of our mission of stewardship. Just as we are called to be faithful with financial resources, we are equally called to be trustworthy in safeguarding data. We are confident that the corrective actions being implemented will ensure that SCU not only meets compliance standards but also reflects our values of integrity, accountability and care. Person Responsible for Corrective Action Plan: Mark Arthur, Chief Financial Officer Anticipated Date of Completion: June 30, 2026
View Audit 364878
Finding 574608 (2024-001)
Material Weakness 2024
Lauderdale County Commission
AL
Questioned Costs Procurement, Suspension & Debarment
The Commission will implement procedures to ensure compliance with the Unjiorm Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 2 CFR 200.3 18 and CFR 200.320 and the Code ofAlabama 1975, Title 39.
The Commission will implement procedures to ensure compliance with the Unjiorm Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 2 CFR 200.3 18 and CFR 200.320 and the Code ofAlabama 1975, Title 39.
View Audit 364869 Questioned Costs: $1
Finding 574590 (2024-002)
Significant Deficiency 2024
Minnesota Prairie County Alliance
MN
Internal Control / Segregation of Duties Questioned Costs Eligibility § 200.303
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
View Audit 364815
Finding 574589 (2024-001)
Significant Deficiency 2024
Minnesota Prairie County Alliance
MN
Questioned Costs Eligibility Significant Deficiency § 200.303
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
View Audit 364815
Finding 574464 (2024-002)
Significant Deficiency 2024
Municipality of Gurabo
PR
Questioned Costs Reporting Significant Deficiency § 200.512
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
View Audit 364800
Finding 574463 (2024-004)
Material Weakness 2024
Winner Regional Healthcare Center
SD
Special Tests & Provisions Questioned Costs Subrecipient Monitoring
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025
View Audit 364799
Adjoin
CA
Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.302
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
Indiana University Health, Inc. and Subsidiaries
IN
Questioned Costs Subrecipient Monitoring Eligibility
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A
View Audit 364785
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