Corrective Action Plans

Finding 575561 (2023-007)

Material Weakness 2023

Greenfield Exempted Village School District

OH

Questioned Costs Reporting

Upon becoming Treasurer in March 2024, I noted an inconsistence in the 507 ESSER fund. I realized the former Treasurer had requested reimbursement twice for the same expenditures thus giving the district a positive balance in the fund. I contacted DEW’s Office of Federal Programs to report the iss...

Upon becoming Treasurer in March 2024, I noted an inconsistence in the 507 ESSER fund. I realized the former Treasurer had requested reimbursement twice for the same expenditures thus giving the district a positive balance in the fund. I contacted DEW’s Office of Federal Programs to report the issue and determine a resolution. I was able to expend the funds on a project approved for ESSER expenditures prior to all grant deadlines. DEW reopened the final expenditure reports allowing the district to correct the past reporting discrepancy. Per DEW emails and communications, the issue is resolved and closed. This issue was caused by the project cash requests not being made on regular intervals and the advance of federal funds from the general fund. The district now submits project cash requests on a monthly basis, to prevent request date overlap and does not advance federal funding from the general fund.

View Audit 365548

Finding 575539 (2023-003)

Significant Deficiency 2023

Mental Health Association in Tulsa, Inc. Dba Mental Health Association Oklahoma

OK

Questioned Costs Procurement, Suspension & Debarment

The Association will no longer issue credit cards in the name of specific programs to prevent repeating this occurrence. Effective immediately all cards will be issued solely to individual staff members, who will be responsible for maintaining appropriate supporting documentation for all transaction...

The Association will no longer issue credit cards in the name of specific programs to prevent repeating this occurrence. Effective immediately all cards will be issued solely to individual staff members, who will be responsible for maintaining appropriate supporting documentation for all transactions. Additionally, staff members will be inactivated in the credit card systems rather than deleted to ensure continuity of records and to maintain accountability. The Association’s COO John Manning will oversee this process.

View Audit 365528 Questioned Costs: $1

Finding 575322 (2023-002)

Material Weakness 2023

San Juan Housing Authority

TX

Questioned Costs HUD Housing Programs Material Weakness

Corrective Action Plan - ACH payments not approved by the Board. Contact person - Executive Director. Corrective action planned - The PHA will implement the control procedure of attaching ACH supporting documentation to a copy of the bank statement and obtaining approval from a Board member authoriz...

Corrective Action Plan - ACH payments not approved by the Board. Contact person - Executive Director. Corrective action planned - The PHA will implement the control procedure of attaching ACH supporting documentation to a copy of the bank statement and obtaining approval from a Board member authorized to sign checks. Anticipated completion date - Within the next fiscal year.

View Audit 365373

Finding 575321 (2023-001)

Material Weakness 2023

San Juan Housing Authority

TX

Questioned Costs HUD Housing Programs Material Weakness

Corrective Action Plan - Financial statements contained material misstatements. Contact person - Executive Director. Corrective action planned - The PHA will hire an outside fee accountant or an employee with accounting experience. Anticipated completion date - Within the next fiscal year.

View Audit 365373

Finding 575294 (2023-002)

Significant Deficiency 2023

Kama'aina Care, Inc.

HI

Questioned Costs Subrecipient Monitoring Reporting § 200.329

Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.

View Audit 365320

Finding 575276 (2023-005)

Significant Deficiency 2023

Standing Rock Sioux Tribe

ND

Eligibility Internal Control / Segregation of Duties Questioned Costs § 200.303

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alv...

Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alvonne Penola, Treatment Program Director Estimated Completion Date: Effective immediately

View Audit 365312

Finding 575275 (2023-010)

Material Weakness 2023

Standing Rock Sioux Tribe

ND

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs

Corrective Action Plan: ALN 93.441: The Tribe’s HR Department will develop and implement policies and procedures requiring that character investigations be performed for all program personnel. In addition, notation of the appropriate independent verification will be clearly notated. ALN 93.575 and 9...

Corrective Action Plan: ALN 93.441: The Tribe’s HR Department will develop and implement policies and procedures requiring that character investigations be performed for all program personnel. In addition, notation of the appropriate independent verification will be clearly notated. ALN 93.575 and 93.596: The Program hired a Training Monitor. The Training Monitor is responsible for scheduling training and ensuring all providers are up to date on training that is required by the CCDF program. The documentation will be kept on file. Person(s) Responsible: Violet Black Cloud, Human Resources Director,Jackie Brownotter, Child Care Assistance Program Director Estimated Completion Date: September 30, 2025, December 31, 2024

View Audit 365312

Finding 575273 (2023-004)

Material Weakness 2023

Standing Rock Sioux Tribe

ND

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance ...

Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance was a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files. Person(s) Responsible: Jackie Brownotter, Child Care Assistance Program Director, Deanne Bear Catches, LIHEAP Director Estimated Completion Date: ALN 93.575 and 93.596 (CPR Certifications): October 2024, ALN 93.575 and93.596 (Provider files): Effective immediately ALN 93.568 (participant files): effectively immediately

View Audit 365312

Finding 575149 (2023-003)

Material Weakness 2023

Municipality of Loiza

PR

Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.339 § 200.403

The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Manageme...

The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed control structure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Coronavirus State and Local Fiscal Recovery Funds Assistance disbursement policies.

View Audit 365237 Questioned Costs: $1

Finding 575148 (2023-002)

Material Weakness 2023

Municipality of Loiza

PR

Questioned Costs Reporting Significant Deficiency

The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.

View Audit 365237

Finding 575141 (2023-001)

Significant Deficiency 2023

Regional School Unit No. 18

ME

Questioned Costs Internal Control / Segregation of Duties

Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate...

Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate compliance. This review has helped us identify areas where improvements can be made to ensure full compliance with these requirements. We have taken the following actions to address the identified compliance issue: 1. Management will proactively include prevailing wage language in any qualifying district construction project bids and contracts. 2. To strengthen our compliance efforts, we have improved monitoring to regularly assess our adherence to prevailing wage rate requirements for projects with federal assistance. This includes periodic reviews of construction projects, and proposed projects, to identify any potential non-compliance issues. Additionally, we will conduct prevailing wage compliance reviews of all certified payrolls as they are received. Management will oversee this monitoring to ensure ongoing compliance.

View Audit 365228

Finding 574716 (2023-003)

Significant Deficiency 2023

City of Wilkes-Barre, Pennsylvania

PA

Questioned Costs Reporting

The City plans to have information ready for auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the City hopes to have cleared by the 2025 audit

View Audit 365027

Finding 574610 (2023-003)

Material Weakness 2023

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 364874

Finding 574609 (2023-003)

Material Weakness 2023

Van Bibber Lake Conservancy District

IN

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

FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We...

FINDING 2023-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Tina Sillery, Financial Clerk Contact Phone Number and Email Address: (765) 739-6671 and vblconservancy@airhop.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Federal funding for the project was fully spent in 2024. In the future, reports required for federal awards will be prepared by the Financial Clerk and reviewed and approved by the District Board or a District Board member. Anticipated Completion Date: August 1, 2025 INDIANA

View Audit 364873

Finding 574586 (2023-004)

Material Weakness 2023

Bristol Bay Borough, Alaska

AK

Subrecipient Monitoring Questioned Costs Material Weakness

Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are pro...

Finding 2023-004: Reporting – Material Weakness in Internal Control Over Compliance and Material Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2025

View Audit 364808

Finding 574585 (2023-003)

Significant Deficiency 2023

Bristol Bay Borough, Alaska

AK

Period of Performance Questioned Costs Allowable Costs / Cost Principles § 200.512

Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging addition...

Finding 2023-003: Reporting - Timely Submission of Financial Reports – Significant Deficiency in Internal Control over Compliance and Noncompliance Name of Contact Person: James Wilson, Borough Manager/Acting Finance Director Corrective Action Plan: The Borough is in the process of engaging additional stakeholders to expedite the completion of future financial reports. Completion Date: September 30, 2025

View Audit 364808

Finding 574543 (2023-003)

Material Weakness 2023

Northshore University Healthsystem

IL

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

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management...

Finding 2023-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple Workday allows costing allocations, which automatically split salaries above and below the cap. This process ensures that only appropriate salaries are charged to the grant. Management will update the salary cap in the system in a timely manner and validate that the system is calculating correctly. Going forward, management will do a quarterly review of the effort distributions, and make adjustments when needed in a timely manner. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 364802 Questioned Costs: $1

Finding 574510 (2023-004)

Material Weakness 2023

Northshore University Healthsystem

IL

Questioned Costs Subrecipient Monitoring

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment an...

Finding 2023-004 – Subrecipient Monitoring Assistance Listing 93.391, Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis. Management will use the system level policy and procedures related to sub-recipient assessment and monitoring that are in place from the Research department. We will leverage key resources within the organization to address areas of noncompliance. Responsible Official: Ashlee Jean Roffe, Director of Nutrition and Community Health, Community CARE

View Audit 364802 Questioned Costs: $1

Finding 574457 (2023-003)

Material Weakness 2023

Pinecrest Medical Care Facility

MI

Questioned Costs Material Weakness Reporting

Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review p...

Finding: 2023-003 Condition: The Facility does not have a review process in place related to the lost revenue calculation input into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program. The Facility also did not have a review process in place for the required submissions. Planned Corrective Action: Management agrees with the finding and will implement a process to ensure an independent review of the reporting submission and its supporting documents is completed prior to finalization. Contact person responsible for corrective action: Brooke Ponchaud, Chief Financial Officer Anticipated Completion Date: 05/01/2024

View Audit 364788

Finding 574154 (2023-002)

Material Weakness 2023

Alaska Native Women's Resource Center

AK

Questioned Costs § 200.512

Management will ensure that future audits are completed timely.

View Audit 364732

Finding 574136 (2023-003)

Significant Deficiency 2023

Urban Indian Center of Salt Lake

UT

Cash Management Questioned Costs Reporting § 200.305

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of ...

Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: UICSL has limited access to its accounting system and removed access by outsourced financial management personnel. In addition to better invoicing structure, UICSL also revised its job-costing system to better comply with these requirements. Together, these systems will be used to request only the amount of attributable ot the programs for reimbursement-based grant funding. Corrective Action Plan: All transactions are logged into the accounting system with appropriate respective grant codes and departments. Invoices and transactions will not be processed without approval and proper coding. UICSL has also implemented a new credit card tracking system along with a purchase order system that is active and maintained by Finance and Accounting. Monthly and quarterly invoices will be prepared for grants in compliance with 2 CFR section 200.305(b). Person Responsible: Matt Poss, Executive Director and Mary Louise Santacaterina, Grants Manager Timeline: Already removed accounting system access by prior outsourced financial managemnet personnel. Monthly check-ins and expenditure reports have been implemented with department leads in 2024. Grants Manager tasked along with Director of Finance of reviewing monthly invoices and ensuring each meets grant and expenditure requirements. All invoices reviewed with grant/project leads and logged appropriately. Staff acountant hired in 2024 to help provide oversight.

View Audit 364707

Finding 574135 (2023-002)

Significant Deficiency 2023

Urban Indian Center of Salt Lake

UT

Matching / Level of Effort / Earmarking Questioned Costs Procurement, Suspension & Debarment § 200.430

Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performe...

Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non‐Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job‐costing system implemented. Auditee Response: The Organization believes that leadership/personnel turnover, along with outsourced financial management, allowed paychecks to be approved without the proper approval flow. We have ensured documenation is downloaded/kept each pay period to ensure such documentation is not lost when a change in service provider is made. Corrective Action Plan: UICSL has moved away from its prior payroll processor to better account for these labor allocations and grant classifications. In our FY23 audit, we requested data from our prior processor multiple times. They were unable to provide some of the reports and data which was purged from their system. Our new payroll processor ensures employees' time is allocated to each grant program and there is a designated reporting funcation allowing us to reviews what is assigned. UICSL also has better defined leadership and directors for each division so there are clearly defined approvers and supervisors for each purchase and transaction. Person Responsible: Matt Poss, Executive Director and Eva Leyer, Human Resources Manager Timeline: UICSL transitioned to a new payroll processor at the end of 2023 and Leadership was designated and assigned for 2024.

View Audit 364707

Finding 573888 (2023-009)

Significant Deficiency 2023

Recreation & Park Commission for Parish of East Baton Rouge

LA

Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment § 200.318

While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility f...

While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. Anticipated completion date: November 1, 2024 Responsible contact person: Don Johnson, Cheif Finance Officer

View Audit 364551

Finding 573885 (2023-005)

Significant Deficiency 2023

Town of East Lyme, Connecticut

CT

Questioned Costs Allowable Costs / Cost Principles Reporting

Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Pr...

Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Project and Expenditure report, that was due by April 30, 2023. Recommendation: CLA recommends the Town implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of their grant agreements. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: Management will implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of our grant agreements. Name(s) of Contact Person(s) responsible for Corrective Active Plan: Kevin Gervais Jr. Planned completion date for corrective action plan: July 2025

View Audit 364541

Finding 573827 (2023-007)

None 2023

City of Cortland

NY

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, ...

Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), §200.512, Report Submission, the Single audit reporting package is required to be filed within the earlier of 30 calendar days after receipt of the auditors' report, or 9 months after the end of the audit period. Cause/Condition: Staffing shortages caused the delays in financial reporting. This deadline was not met on a timely basis for the year ended December 31, 2023. Effect: As a result, the entity is not incompliance with §200.512 of the Uniform Guidance. Recommendation: We recommend the requirements of §200.512 of the Uniform guidance be adhered to by striving to have all information required for the audit available on a timely basis. This will help to ensure timely audit report issuance and compliance with the filing deadline. Response: The City is still facing staffing shortages and is working to get the subsequent financial statements completed. It is expected the 2024 reporting package will be filed on time. Corrective Action Plan: The City has hired a full complement of staff in the Finance department, and anticipates timely filings going forward. Anticipated Completed Date: September 30, 2025. Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance

View Audit 364485

Corrective Action Plans

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