Corrective Action Plans

Finding 575148 (2023-002)

Material Weakness 2023

PR

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 574716 (2023-003)

Significant Deficiency 2023

City of Wilkes-Barre, Pennsylvania

PA

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 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 574592 (2023-005)

Significant Deficiency 2023

Southwest Regional Development Commission

MN

Reporting Internal Control / Segregation of Duties Significant Deficiency

Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective ...

Finding Summary: There was no formal review documented over several reports tested, some reports were not submitted timely as required by the specific award requirements, and one report did not have supporting documentation on hand. Responsible Individuals: Jay Trusty, Executive Director Corrective Action Plan: Management has reviewed the findings and taken steps in developing an internal control review process. The Commission implemented procedures to ensure all reports have proof of review and submission, as well as working towards submitting all reports timely. Anticipated Completion Date: June 2026

View Audit 364840

Finding 574586 (2023-004)

Material Weakness 2023

Bristol Bay Borough, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting

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 Allowable Costs / Cost Principles Reporting § 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 574582 (2023-006)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants managemen...

Finding 2023-006 – Reporting Assistance Listing 21.027, Coronavirus State and Local Fiscal Recovery Fund The management has taken corrective action to ensure accurate SEFA reporting. These actions include clarifying reporting timelines, improving coordination between finance and the grants management team, and implementing new policy and procedures for SEFA reporting. Finance and grants management staff will jointly review all grant activity at year-end to ensure proper inclusion in SEFA. Management acknowledges the importance of accurate SEFA reporting and is committed to strengthening internal controls to prevent similar issues in future reporting periods. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 364802

Finding 574484 (2023-002)

Material Weakness 2023

Northshore University Healthsystem

IL

Allowable Costs / Cost Principles Reporting

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paper...

Finding 2023-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Assistance Listing Multiple The new Workday time and effort certification is now operational. Each individual is able to certify their own time and effort in the system, which eliminates manual tracking and paperwork. Management will follow up and validate the effort certification is occurring in a timely manner. Management is currently drafting the policy to align with the new process. There will be continuous staff training and monitoring in this area. Responsible Official: Robert Stanton, Assistant Vice President, Research and Financial Operations, NSH Research Central Office

View Audit 364802

Finding 574483 (2023-001)

Material Weakness 2023

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconcil...

Finding 2023-001 – Reporting Assistance Listing Multiple In the immediate term, management will work with the grant consultant to modify the existing report to capture all the costs in the general ledger related to grants. Management will start a quarterly review process of the report with reconciliation to the grant detail. In addition, prior to the UG audit, management will start a year-end review process to ensure accurate and timely reporting. Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 364802

Finding 574457 (2023-003)

Material Weakness 2023

Pinecrest Medical Care Facility

MI

Material Weakness Reporting Matching / Level of Effort / Earmarking

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 574136 (2023-003)

Significant Deficiency 2023

Urban Indian Center of Salt Lake

UT

Cash Management 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 574081 (2023-001)

Significant Deficiency 2023

Hollandale School District

MS

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hollandale School District has prepared and hereby submits the following corrective actio...

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hollandale School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Dr. Mario Willis Title: Superintendent B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and data collection form are submitted to the Federal Audit Clearinghouse within established timeframe and financial statements are prepared timely. C. Anticipated completion date of corrective action: Immediately

View Audit 364666

Finding 573970 (2023-009)

None 2023

City of Biddeford

ME

Reporting Procurement, Suspension & Debarment § 200.510

Management’s Response and Corrective Action Plan: Grant review is included within the month-end close procedure referenced in the response to 2023-001. The procedure includes defined roles and responsibilities by position.

View Audit 364578

Finding 573969 (2023-008)

Material Weakness 2023

City of Biddeford

ME

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is au...

Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is authorized to submit. The procedure includes timelines and authorizations requiring all grants to be entered into the City’s financial management software suite to ensure complete and timely project monitoring. All users have access to the financial software and have real-time access to all data.

View Audit 364578

Finding 573885 (2023-005)

Significant Deficiency 2023

Town of East Lyme, Connecticut

CT

Allowable Costs / Cost Principles Reporting Significant Deficiency

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 573858 (2023-001)

None 2023

Midd-West School District

PA

Subrecipient Monitoring Reporting

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...

The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.

View Audit 364514

Finding 573855 (2023-002)

None 2023

Basic Health International

PA

Reporting § 200.512

BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. BHI has also engaged an audit firm to perform it...

BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. BHI has also engaged an audit firm to perform its federally-required federal financial statement and single audits each year. This reminder and timeline has been put on the BHI shared calendar so that this task is not missed in the future.

View Audit 364502

Finding 573854 (2023-001)

Material Weakness 2023

Basic Health International

PA

Reporting Material Weakness

BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. Furthermore, BHI has implemented procedures to ...

BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. Furthermore, BHI has implemented procedures to ensure adequate internal control over financial processes. For one, all the invoicing on all grant and contract accounts are done monthly. The BHI admin/program manager prepares all invoices on a monthly basis which are then reviewed by Chief Operating Officer and finally approved by the Principal Investigator. All financial transactions are recorded in QuickBooks so that bank and credit card accounts can be reconciled monthly. And lastly, an automated solution has been implemented to keep all bill payment and approvals strictly separate.

View Audit 364502

Finding 573841 (2023-002)

Material Weakness 2023

City of Tenino

WA

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

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee p...

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee plans to take in response to the finding: The City will include the required wage rate provisions in future contracts and will require weekly certified payroll reports prior to paying the contractor for the appropriate periods. Anticipated date to complete the corrective action: Immediately

View Audit 364492

Finding 573834 (2023-008)

Material Weakness 2023

City of Cortland

NY

Reporting § 200.502

Corrective Action Plan Financial Statement Finding: 2023-008 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee’s ...

Corrective Action Plan Financial Statement Finding: 2023-008 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee’s financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of the SEFA. The SEFA is the basis for the auditor’s identification of major programs. Cause/Condition: The City does not have a method to accurately track the related expenditures for reporting. The City's initial SEFA provided for the audit was incomplete and contained inaccurate program expenditure amounts. In particular, there were multiple federal programs that were materially misstated; including the following major federal program for the year under audit: 1. ALN 14.228 Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii In addition, there were multiple federal programs that were not identified on the initial SEFA for the year under audit: 1. ALN 20.600 / 20.616 Highway Safety Cluster 2. ALN 66.818 Brownfield Multipurpose, Assessment, Revolving Loan Fund, and Cleanup Cooperative Agreements 3. ALN 66.458 Capitalization Grants for Clean Water State Revolving Funds 4. ALN 93.568 Low-Income Home Energy Assistance 5. ALN 97.039 (COVID-19) Disaster Grants - Public Assistance (Presidentially Declared Disasters) Effect: A Uniform Guidance compliance audit is based on the premise that management must comply with federal statutes, regulations and the terms and conditions of the federal awards it receives. Without identifying the funds as federal, the auditee may not have complied with those requirements. In addition, there is increased risk regarding the accurate reporting of grant expenditures and noncompliance with policies and procedures surrounding the recording of federal awards. Recommendation: We recommend the City develop and implement procedures to ensure that information related to all federal awards is accumulated to assist in the preparation of the SEFA. In addition, we recommend management of the City verify the completeness and accuracy of the amounts reported on the SEFA. Response: The City agrees with the finding. Corrective Action Plan: The City will include tracking of federal awards in the Capital Project tracking process. Capital projects will be reflected in a separate budget alongside the operational budget beginning in FY 2026. Anticipated Completed Date: July 31, 2025 for the tracking process; December 20, 2025 for the budget. Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance

View Audit 364485

Finding 573827 (2023-007)

None 2023

City of Cortland

NY

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

Finding 573744 (2023-001)

Material Weakness 2023

Florence-Carlton School District 15-6

MT

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

We have reviewed the deficiencies and have included our responses to each below. 1. Finding # 2023-001 –Late filing of Financial and Audit. Reports had not been filed within nine months after the fiscal year end of Jun. 30, 2023, which should have been by Mar. 31, 2024. Management Response: Flore...

We have reviewed the deficiencies and have included our responses to each below. 1. Finding # 2023-001 –Late filing of Financial and Audit. Reports had not been filed within nine months after the fiscal year end of Jun. 30, 2023, which should have been by Mar. 31, 2024. Management Response: Florence Carlton School District 15-6 has historically filed audit reports in a timely manner to the respective agencies. The district experienced multiple key changes in financial management positions within a short period, which slowed down the audit process. Florence Carlton has filed our audit reports and data collection forms with the state, federal, and credit agencies, but this process also lacked training. Internal control procedures have been outlined and implemented for the future, including the Schedule of Federal Awards, and will continue to be implemented moving forward. The lack of Standard Working Instructions (SWI) contributes to the lack of consistency, compliance, and training. I have developed SWIs with Visual (photos or videos) directions for each step in all areas of a broad base of responsibility of the clerk position.

View Audit 364413

Finding 573734 (2023-001)

Significant Deficiency 2023

Iowa Northland Regional Housing Authority

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.

View Audit 364398

Finding 573733 (2023-007)

Material Weakness 2023

Village of New Waterford

OH

Reporting Subrecipient Monitoring § 200.328 § 200.329

The village is currently reviewing the Federal Requirement for reporting and how the village will be able to track and handle this reporting in the future. In regard to monthly reporting the village has a population of approximately 1500 residents and received approximately $50,000 SLFRF funds. Wel...

The village is currently reviewing the Federal Requirement for reporting and how the village will be able to track and handle this reporting in the future. In regard to monthly reporting the village has a population of approximately 1500 residents and received approximately $50,000 SLFRF funds. Well below the quarterly requirements and were only required to file yearly per the guidelines listed by the U.S. Department of Treasury’s own reporting guidelines. See below chart. Please take note that the Village has reported each year since 2022 as required. A copy of the yearly reports are available if needed.

View Audit 364392

Finding 573731 (2023-005)

Material Weakness 2023

Village of New Waterford

OH

Reporting § 200.502 § 200.510

As stated in the finding (2023-005) the Village was unaware of the monies being Federal Monies as they were received from a State of Ohio distribution, and after a discussion with the auditors the Village prepared the required reports. The village, being a small municipality, does not receive feder...

As stated in the finding (2023-005) the Village was unaware of the monies being Federal Monies as they were received from a State of Ohio distribution, and after a discussion with the auditors the Village prepared the required reports. The village, being a small municipality, does not receive federal funds routinely and I believe the Coronavirus funds will not be something the village anticipates receiving in the future. – Mayor M. Shane Patrone

View Audit 364392

Corrective Action Plans

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