Corrective Action Plans

Finding 521127 (2023-003)

Material Weakness 2023

CO

Internal Control / Segregation of Duties Reporting

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant fu...

Problem: Lake County Government did not file quarterly or annual reports as required by Coronavirus State and Local Fiscal Recovery Funds as per Department of Treasury. Actions Steps: All Coronavirus State and Local Fiscal Recovery Funds must be managed going forward as per the standardized grant funding policy in both process and procedure. Status: Granted funds awarded to Lake County Government are managed and controlled via the BOCC voted and approved Lake County Grant Policy. Dates: July 2024 to present Goal: To accurately and reliably manage and report on all funds granted awarded to Lake County Government.

View Audit 341067

Finding 521112 (2023-008)

None 2023

Espanola Public School District

NM

Reporting § 200.512

Views of Responsible Officials and Planned Corrective Actions – The District is committed to enhancing its processes to ensure timely and efficient preparation for audit requests. To align with the standards set forth in the New Mexico Administrative Code Title 2, Chapter 2, Part 2, we will implemen...

Views of Responsible Officials and Planned Corrective Actions – The District is committed to enhancing its processes to ensure timely and efficient preparation for audit requests. To align with the standards set forth in the New Mexico Administrative Code Title 2, Chapter 2, Part 2, we will implement more robust internal procedures to improve audit readiness and ensure that all necessary documentation is readily available. These efforts will support compliance with deadlines and strengthen overall audit management across the District’s operations. Responsible Parties: Director of Finance and the District’s business office. Estimated Completion Date: December 30, 2024.

View Audit 341061

Finding 521048 (2023-001)

Significant Deficiency 2023

Meadows Mental Health Policy Institute for Texas

TX

Reporting Significant Deficiency Internal Control / Segregation of Duties

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 20...

The Meadows Mental Health Policy Institute for Texas (the Institute) respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: 01/01/2023 – 12/31/2023 The findings from the Schedule of Findings and Questioned Costs identified in the December 05, 2024, audit report are discussed below. Findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Awards Audit Significant Deficiency Federal Awards Program Audit Findings and Recommendations Finding 2023-001: Reporting – significant deficiency in internal control over compliance and compliance finding. All federal grants. Criteria: Grantees who are subject to single audit requirements are required to submit their Data Collection form to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditors’ report or 9 months after the audit period. Condition: The Institute’s Data Collection form was late for the years ended December 31, 2022, and 2023. Cause: Delays in completing the audits resulted in the Data Collection forms being submitted after 9 months from the end of the audit report. Effect: The Institute was not in compliance with single audit reporting requirements. Recommendation: Internal controls and processes should be implemented to ensure audits are completed in a timely manner to meet federal reporting deadlines. Institute Action Plan: • Hire new finance and accounting senior management [completed November 2024]. o Hired new CFO (October 2024; started January 02, 2025) o Hired new Controller (November 2024; starts February 17, 2025) Establish timeline for review and acceptance of 2024 audit [initiated December 2024]. o By May 01, 2025: Institute submits 2024 General Ledger and Trial Balance to auditor o May 01, 2025 – May 11, 2025: Auditor sends sample and other requests for information o May 12, 2025 – May 23, 2025: Audit fieldwork o Week of July 07, 2025: Auditor sends draft audit report to Institute management for review. o Week of July 21, 2025: Institute management reviews draft audit report and notes areas needing clarification and/or corrections. o By Week of August 11, 2025: Auditor provides a final revised audit report to Institute management. o Week of August 18, 2025: Institute management sends audit report to the Institute Board’s Audit and Finance Committee for review. o By week of September 1, 2025: The Audit and Finance Committee meets to review and accept final audit report on behalf of the Board. o By September 15, 2025: Data Collection Form is submitted to the Federal Audit Clearinghouse (i.e., well in advance of the September 30, 2025, submission due date for the Data Collection Form). o October 29, 2025: The Institute Board ratifies the Audit and Finance Committee’s acceptance of final audit report. • Q1-Q2 2025: Perform gap analysis evaluation of existing Accounting staff and address any gaps in coverage and provide access to and training on financial systems and historical data archives [initiated and ongoing]. Corrective Action Contact Person(s): Maryana Geller, Chief Financial and Administrative Officer Planned Completion Date for Corrective Action Plan: September 15, 2025

View Audit 340943

Finding 521010 (2023-003)

Material Weakness 2023

Pittsburgh Innovation District D/b/a Innovatepgh Partnership

PA

Subrecipient Monitoring Reporting

NEED FROM CLIENT…...

View Audit 340882

Finding 521009 (2023-004)

Material Weakness 2023

City of El Monte

CA

Reporting

New procedures have been established to ensure the separation of duties and responsibilities between the individuals who prepare grant reporting and the individuals who review the reports starting FY2024. The accounting manager gathers the data and prepares the grant reporting and then the Finance ...

New procedures have been established to ensure the separation of duties and responsibilities between the individuals who prepare grant reporting and the individuals who review the reports starting FY2024. The accounting manager gathers the data and prepares the grant reporting and then the Finance Director reviews and approves the reporting before it is submitted.

View Audit 340881

Finding 521006 (2023-001)

Material Weakness 2023

City of El Monte

CA

Reporting

The City hired an additional accountant on July 1, 2023, to oversee all of the Economic Development grants. This accountant is responsible for the review of all reporting and submission.

View Audit 340881

Finding 520959 (2023-002)

Material Weakness 2023

Hui No Ke Ola Pono, Inc.

HI

Reporting

During the fiscal year, funding sources or grantors, were not clearly defined by the grantors documents on the type of funding received by HNKOP. Due to the inability to define the funding source, these expenses were not included on the SEFA report. Since January 2023, all awards are verified with...

During the fiscal year, funding sources or grantors, were not clearly defined by the grantors documents on the type of funding received by HNKOP. Due to the inability to define the funding source, these expenses were not included on the SEFA report. Since January 2023, all awards are verified with the grantor if the funds are from a federal award, and has been noted on the SEFA report as such.

View Audit 340855

Finding 520958 (2023-001)

Material Weakness 2023

Hui No Ke Ola Pono, Inc.

HI

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After app...

Internal control over payroll and disbursements In January 2023 changes to any pay rates were submitted on a Personnel Action Form (PAF) by the Operations Manager. The PAF included the old pay rate and the new pay rate and was submitted to the Executive Director for review and approval. After approval, the form was filed in the employees paper file, as well as uploaded to their electronic record on the ProService platform. In May 2024, we hired a Human Resources Specialist who is responsible for updating and maintaining all personnel files and processing of payroll records. In October 2023, we hired an Accounting Specialist (AS) who is responsible for the processing of all vendor disbursements. Prior to ordering items or services, a Purchase Requisiton (PR) is submitted by the program manager to the Executive Director or Programs Director for review and approval. Upon approval the PR is submitted to the Controller for expense and grant coding. PR is then submitted to the AS to assign a PR number and enter the expenses on the PR tracking log. When the PR has been assigned a PR number it is sent to the Operations Manager for purchasing. When the invoice is received the PR is matched to the invoice indicating proper approvals. If the purchase is over $5,000, a Procurement form is completed to solicit 3 bids and reviewed and approved by the Executive Director. If the purchase is over $20,000, the Procurement form is submitted to the Board of Directors for approval. All Procurement forms are attached to invoices for payment processing. Internal control over account balances During the fiscal year, it was noted that there were credit card entries that were duplicated, and have been corrected as of the date of this report. Due to miscommunication with the previous fiscal staff, payments made by credit card were entered as an invoice and as an adjusting journal entry.

View Audit 340855

Finding 520863 (2023-003)

None 2023

Northern Michigan Health Consortium

MI

Allowable Costs / Cost Principles Reporting § 200.512

It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of feder...

It is the responsibility of the Finance Supervisor to ensure all contracts entered into includes language indicating if the funding is federal or state. If it is federal funding, the contract must include the federal assistance listing number, which will be reported on the year-end schedule of federal awards. A single audit will be performed if the federal expenditures reach the maximum allowable per auditing standards. If a single audit is required, it will be completed and submitted to the appropriate grantors within nine months of the end of the fiscal year.

View Audit 340690

Finding 520847 (2023-005)

Material Weakness 2023

Municipality of Ceiba

PR

HUD Housing Programs Reporting

We concur with the finding. During the fiscal year 2024-2025, both reports for fiscal years 2021 and 2022 will be filed. Therefore, the conditions of the findings have been corrected.

View Audit 340664

Finding 520803 (2023-003)

Material Weakness 2023

County of Trinity

CA

Subrecipient Monitoring Reporting Program Income

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training wi...

Federal program title – Community Development Block Grant – CDBG – CFDA 14.228 Recommendation: CLA recommends the County develop procedures, such as reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training with employees to ensure that knowledge is shared among the team members. Action taken in response to finding: The Grants department had two employees in FY 22/23. The Grant coordinator and assistant both terminated county employment in fiscal year 22/23 and left virtually no records. Information and materials, they did leave behind were stuffed in boxes and tracking in the electronic workbook was not fully completed. Admin staff trained the Grant employees but was unaware they were not following the process and procedures, and only saving information to their personal computer. Current admin staff requested the documents from prior staff members and they were received, though we are unsure if all were sent. Staff is doing their due diligence and working diligently to get back on track in monitoring activities, and train the newly hired staff. There is insufficient budget to hire the staff needed to fully monitor the CDBG efforts. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for correcting action plan: Undetermined at this time as the staff continues their current minimal CDBG efforts while still maintaining all other duties, and being short staffed. Existing CDBG workload is being closed out as fast as possible.

View Audit 340608

Finding 520779 (2023-003)

Significant Deficiency 2023

Progress House Inc.

CA

Reporting Allowable Costs / Cost Principles

Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of feder...

Views of responsible officials and corrective action: We have adopted a SEFA worksheet to track federal award expenditures for each individual federal program to include the CFDA or other identifying number when the CFDA information is not available. Included in the SEFA worksheet, tracking of federal awards received as a subrecipient, including the name of the pass-through entity and the identifying number assigned by the pass-through entity. All federal expenditures will be categorized per our contract statement on allowable cost expenses. Responsible Individual: Brangwyn Foley, Office Manager Implementation Date: July 2023

View Audit 340574

Finding 520702 (2023-003)

Material Weakness 2023

Community Health and Emergency Services, Inc.

IL

Reporting Allowable Costs / Cost Principles

2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedure...

2023-003 Inaccurate Schedule of Expenditures of Federal Awards Provider Relief Fund – CFDA #93.498 Condition: Management has all the information to complete the schedule of expenditures of federal awards in compliance with the Uniform Guidance but had inaccuracies discovered during audit procedures. Federal expenditures of $1,560,441 were excluded from the schedule but were determined to have been reported as spent during the fiscal year. There were also $99,895 in federal expenditures reported for other grants that were determined to be overstated. Action Taken: • Management will prepare the schedule of expenditures of federal awards as part of the year end closing process each year to determine our audit requirements under Uniform Guidance and provide the schedule to the audit firm during the financial audit process. Anticipated Date of Completion and Name of Contact Person: June 30, 2024 – J.P. Champion, Chief Financial Officer

View Audit 340436

Finding 520695 (2023-001)

Significant Deficiency 2023

Fairfield University

CT

Student Financial Aid Special Tests & Provisions Reporting

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Offi...

Finding No. 2023-001 – Significant Deficiency and Noncompliance: Special Tests and Provisions – Enrollment Reporting Corrective Action The corrective action that will be taken is a graduates only enrollment report will be supplied to the National Student Clearinghouse (NSC) by the Registrar’s Office on a consistent schedule of submission within 60 days of each graduation period. Persons Responsible for Corrective Action The corrective action plan will be completed by Walter Rankin, Vice Provost for Graduate Continuing and Professional Studies and Danielle Quilligan, University Registrar. Completion Date Initial corrective action was completed by Lynn Kohrn, University Registrar and Allison Henderson, Assistant Registrar in October, 2023 with the submission of a graduates only enrollment report to the third-party service provider NSC. A schedule for consistent submissions of a graduates only enrollment report has already been provided to the NSC.

View Audit 340417

Finding 520658 (2023-004)

Significant Deficiency 2023

Autonomous Municipality of Mayaguez

PR

Reporting

#VALUE!

View Audit 340367

Finding 520582 (2023-001)

Material Weakness 2023

Centennial Square

MN

Material Weakness Reporting Internal Control / Segregation of Duties

Management will continue to rely on CliftonLarsonAllen to draft the financial statements and the related notes to the financial statements, and will review, approve, and accept responsibility for the annual financial statements prior to their issuance.

View Audit 340189

Finding 520577 (2023-001)

Significant Deficiency 2023

United States Breastfeeding Committee, Inc.

IL

Period of Performance Reporting

Expenses Reported in Proper Period Contact Persons Responsible for the Corrective Action Plan: Tiana Pyles, Board Chair, and Arissa Palmer, Board Treasurer Corrective Action Plan: We agree with the finding and have implemented an internal tracking system to monitor employee’s professional developmen...

Expenses Reported in Proper Period Contact Persons Responsible for the Corrective Action Plan: Tiana Pyles, Board Chair, and Arissa Palmer, Board Treasurer Corrective Action Plan: We agree with the finding and have implemented an internal tracking system to monitor employee’s professional development allowance and ensure expenses are recorded in the proper period. Anticipated Completion Date: March 31, 2025

View Audit 340176

Finding 520559 (2023-002)

Significant Deficiency 2023

Housing Authority of Portage County

WI

Allowable Costs / Cost Principles Reporting

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Autho...

The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the schedule of expenditures of federal awards.

View Audit 340118

Finding 520345 (2023-004)

Material Weakness 2023

Talbot County Board of Education

GA

Questioned Costs Subrecipient Monitoring Cash Management § 200.302 § 200.303 § 200.511

FA 2023-004 Strengthen Controls over Financial Reporting Compliance Requirement: Reporting Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance List...

FA 2023-004 Strengthen Controls over Financial Reporting Compliance Requirement: Reporting Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010 (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: $84,283 Repeat of Prior Year Finding: FA 2022-004, FA 2021-002, FA 2019-002 Description: The School District did not file accurate completion reports for the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawdowns are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will include detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

View Audit 340053 Questioned Costs: $1

Finding 520340 (2023-002)

Material Weakness 2023

Talbot County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.430

FA 2023-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Ge...

FA 2023-002 Improve Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund, COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D210012 (Year: 2021) S425U210012 (Year: 2021) S425W210011 (Year: 2021) Questioned Costs: $98,807 Repeat of Prior Year Finding: FA 2022-002 Description: A review of expenditures charged to the Elementary and Secondary Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that expenditures were appropriately documented to support allowability. Corrective Action Plans: District office will review payroll process and develop a procedure to ensure proper documentation is kept in an orderly manner. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

View Audit 340053 Questioned Costs: $1

Finding 520338 (2023-001)

Material Weakness 2023

Talbot County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.430

FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: ...

FA 2023-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.010 - Title I Grants to Local Educational Agencies Federal Award Number: SO10A210010-21A (Year: 2022) SO10A220010 (Year: 2023) Questioned Costs: $6,942 Repeat of Prior Year Finding: FA 2022-001 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Title I Grants to Local Educational Agencies program. Corrective Action Plans: District office has put procedures in action to make sure that all drawbacks are in line with expenditures. All draw down packets will be viewed and signed off by federal program director. This packet will included detail expenditure sheet for the month, year to date expenditure report and a cover sheet. Estimated Completion Date: December 31, 2024 Contact Person: Torrence H. Freeman, III CFO Telephone: 706-665-8577 Email: tfreeman@talbot.k12.ga.us

View Audit 340053 Questioned Costs: $1

Finding 520251 (2023-004)

Material Weakness 2023

Briar Cliff University

IA

Student Financial Aid Matching / Level of Effort / Earmarking Reporting

Management’s Response: Briar Cliff will work with Ellucian on a review of the setup and processes that the Registrar’s Office currently follows, and we will work with Ellucian for recommendations on implementing a process/procedure that ensures the Registrar’s Office has been trailed and is in comp...

Management’s Response: Briar Cliff will work with Ellucian on a review of the setup and processes that the Registrar’s Office currently follows, and we will work with Ellucian for recommendations on implementing a process/procedure that ensures the Registrar’s Office has been trailed and is in compliance.

View Audit 339885

Finding 520232 (2023-005)

Significant Deficiency 2023

New York State Sheriffs' Association

NY

Reporting § 200.512

The amount of backup source documents and intensity of the single audit was very unfamiliar to staff responsible for providing those materials. Recent hire of Finance Assistant, Paula Gwinnell and her gained experience will help move the audit along in a more timely manner.

View Audit 339861

Finding 520224 (2023-003)

Significant Deficiency 2023

Central Montana Regional Water Authority

MT

Reporting

The Project Administrator will work with the outside accountant on record keeping of the Authority, and going forward, submit any required reports based on direction provided by the grantors. Responsible Officials: Monty Sealey, Project Manager and Melissa Carlson, Accountant Expected Completion Da...

The Project Administrator will work with the outside accountant on record keeping of the Authority, and going forward, submit any required reports based on direction provided by the grantors. Responsible Officials: Monty Sealey, Project Manager and Melissa Carlson, Accountant Expected Completion Date: by June 30, 2025

View Audit 339789

Finding 520162 (2023-003)

Significant Deficiency 2023

Center for Religion and Diplomacy, Inc.

DC

Reporting Subrecipient Monitoring Significant Deficiency § 200.510

Management understands that all Federal programs (even as a sub-awardee) need to be part of the SEFA schedule. Going forward Financial Administrator will ensure to include all programs associated with Federal Award (direct or indirect) on the SEFA schedule. Carefully review all contracts to ensure t...

Management understands that all Federal programs (even as a sub-awardee) need to be part of the SEFA schedule. Going forward Financial Administrator will ensure to include all programs associated with Federal Award (direct or indirect) on the SEFA schedule. Carefully review all contracts to ensure that all contracts that are included, if any questions arise, a third-party consultant will be contacted. Anticipated Completion Date: June 30, 2024. Responsible Contact Party: Olga Batkhan, Financial Administrator.

View Audit 339747

Corrective Action Plans

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