Corrective Action Plans

Finding 1156816 (2023-002)

Material Weakness 2023

TX

Questioned Costs Reporting § 200.328

Finding: The County’s first quarter 2023 performance report incorrectly included expenditures that were incurred throughout fiscal year 2022. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed ...

Finding: The County’s first quarter 2023 performance report incorrectly included expenditures that were incurred throughout fiscal year 2022. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Recommendation: Management should implement policies and procedures to ensure required reports are completed accurately and filed by their respective due dates as required by the grant agreement and Uniform Guidance. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports and the County’s Annual Comprehensive Financial Report (ACFR). Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2025 Status: In progress

View Audit 369193

Finding 1156794 (2023-004)

Material Weakness 2023

Partners Inland Northwest

WA

Equipment & Real Property Management Special Tests & Provisions Material Weakness

2023-004 The Emergency Food Assistance Program (TEFAP) and Commodity Supplemental Food Program (CSFP) Reporting Corrective action planned: This error was identified in preparation of the 2024 audit in July 2025. We have implemented a system to track federal noncash award inflows and outflows accordi...

2023-004 The Emergency Food Assistance Program (TEFAP) and Commodity Supplemental Food Program (CSFP) Reporting Corrective action planned: This error was identified in preparation of the 2024 audit in July 2025. We have implemented a system to track federal noncash award inflows and outflows according to bills of lading provided by the Contractor. We will reconcile our inventory at a minimum annually. Anticipated completion date: October 31, 2025 Contact person responsible for corrective action: Justin Carlile Justinc@partnersinw.org

View Audit 369170

Finding 1156443 (2023-001)

Material Weakness 2023

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

Reporting Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore...

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2024 and 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following additional items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Deadlines (monthly, quarterly, etc.) o Proof of submission

View Audit 368718

Finding 1156120 (2023-009)

Material Weakness 2023

City of Stamford, Connecticut

CT

Reporting

2023-009 – Material Weakness & Noncompliance: SEFA and SESA Accuracy Corrective Action: Require Grants Department to reconcile SEFA and SESA quarterly to general ledger. Develop checklist for grant entry (program name, ALN, award year, grant number). Implement ERP grant tracking functionality. Timel...

2023-009 – Material Weakness & Noncompliance: SEFA and SESA Accuracy Corrective Action: Require Grants Department to reconcile SEFA and SESA quarterly to general ledger. Develop checklist for grant entry (program name, ALN, award year, grant number). Implement ERP grant tracking functionality. Timeline: Initiated in FY25; verified in FY26 reporting. Responsible Party: Grants Officer with Staff Accountant assigned to grants portfolio

View Audit 368535

Finding 1156113 (2023-011)

Material Weakness 2023

City of Stamford, Connecticut

CT

Reporting Eligibility Significant Deficiency § 200.512

2023-011 – Significant Deficiency: Late Single Audit Reporting Packages Corrective Action: Centralize grant management and reporting in the Grants Department. Require reconciliation of SEFA and SESA to the general ledger and project subledgers. Mandate annual training for department grant personnel ...

2023-011 – Significant Deficiency: Late Single Audit Reporting Packages Corrective Action: Centralize grant management and reporting in the Grants Department. Require reconciliation of SEFA and SESA to the general ledger and project subledgers. Mandate annual training for department grant personnel on federal/state reporting requirements. Timeline: Initiated with ERP implementation FY24; full compliance by FY26 reporting. Responsible Party: Grants Officer with support from Controller’s Office

View Audit 368535

Finding 1156031 (2023-010)

Material Weakness 2023

City of Stamford, Connecticut

CT

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs § 200.302

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous ...

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous documentation of payroll and invoices tied to FEMA projects. Grants Officer to oversee federal disaster recovery funds. Timeline: New procedures adopted October 2025; effective for any new FEMA claims. Responsible Party: Grants Officer in coordination with relevant departments

View Audit 368535 Questioned Costs: $1

Finding 1155970 (2023-005)

Material Weakness 2023

Incline Village General Improvement District

NV

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.512

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the f...

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the fiscal year-end. Condition The District’s reporting package for the fiscal year ended June 30, 2023, was not submitted to the Federal Audit Clearinghouse within the required timeframe. As of the date of this report, the reporting package has not yet been submitted. Cause The District did not have adequate procedures in place to ensure timely completion of the financial audit and preparation of the reporting package. Effect The District did not comply with the Uniform Guidance submission deadline, which may impact the timeliness of federal oversight and potentially affect future federal funding decisions. Questioned Costs No questioned costs were identified as a result of our procedures. Context/Sampling The FY2023 Single audit was performed in 2025 after it was determined that the grant funds were expended on eligible activities, triggering the Single Audit requirement. The delay was due to the District not identifying the requirement timely and lacking procedures to ensure prompt submission. Recommendation We recommend that the District implement processes and internal controls to ensure future Single Audits are completed and submitted within the required timeframe. Management’s Corrective Action Planned Management concurs with the recommendation. IVGID will establish a procedure to review and reconcile grants both federal and state at year-end to determine the need for a single audit and submission to the required agencies.

View Audit 368379

Finding 1155813 (2023-003)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Questioned Costs Subrecipient Monitoring Reporting § 200.328

Views of Responsible Officials and Planned Corrective Actions: ICFJ's financial and programmatic reports are primarily digital. ICFJ uses access restricted SharePoint and Salesforce applications for all document storage. Finance, Programs and IT has worked together to improve completeness and consis...

Views of Responsible Officials and Planned Corrective Actions: ICFJ's financial and programmatic reports are primarily digital. ICFJ uses access restricted SharePoint and Salesforce applications for all document storage. Finance, Programs and IT has worked together to improve completeness and consistency of all financial and programmatic records storage.

View Audit 368202

Finding 1155812 (2023-002)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Subrecipient Monitoring Reporting

Views of Responsible Officials: All applicable subawards (including any cost-related modifications) are now registered in the FFATA Subaward Reporting System (FSRS.gov). ICFJ’s Budget & Compliance Officer carefully reviews all new Federal awards received by ICFJ to ensure all applicable subawards ar...

Views of Responsible Officials: All applicable subawards (including any cost-related modifications) are now registered in the FFATA Subaward Reporting System (FSRS.gov). ICFJ’s Budget & Compliance Officer carefully reviews all new Federal awards received by ICFJ to ensure all applicable subawards are registered at FSR.gov in compliance with FFATA requirement. Periodic trainings on FFATA compliance for all staff who work on federally-funded awards have been conducted and are scheduled at least annually. FFATA requirement is a checklist item during onboarding of new awards.

View Audit 368202

Finding 1155745 (2023-002)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting § 200.303 § 200.502 § 200.510

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026

View Audit 368033

Finding 1155735 (2023-001)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting Questioned Costs § 200.303

As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the con...

As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Complete. AL No. 93.498 ended in 2023.

View Audit 368033

Finding 1155735 (2023-001)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting Questioned Costs § 200.303

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026

View Audit 368033

Finding 1155631 (2023-001)

Material Weakness 2023

Philadelphia Area Labor Management Committee

PA

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.512

U.S. Department of Commerce, Philadelphia Works, Inc. 2023-1 Timely submission of Data Collection Form – Assistance Listing Number 11.307 Recommendation: We recommend PALM engage a certified public accountant to conduct a Single Audit as long as the PALM meets the Single Audit criteria Explanation o...

U.S. Department of Commerce, Philadelphia Works, Inc. 2023-1 Timely submission of Data Collection Form – Assistance Listing Number 11.307 Recommendation: We recommend PALM engage a certified public accountant to conduct a Single Audit as long as the PALM meets the Single Audit criteria Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has engaged a certified public accountant to complete a Single Audit and assist in the submission of the data collection form. Name of contact person responsible for corrective action: Anthony Wigglesworth, Executive Director. Corrective action plan has been implemented prior to the due date of the December 31, 2024 data collection form.

View Audit 367886

Finding 1155487 (2023-003)

Material Weakness 2023

Oak Hill United School Corporation

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.302 § 200.303 § 200.328 § 200.329

FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not lim...

FINDING 2023-003 Finding Subject: COVID-19-Education Stabilization Fund - Reporting Summary of Finding: The School Corporation was required to submit an annual data report to the Indiana Department of Education (IDOE) via JotForm, a form/report builder. Data to be submitted included, but was not limited to, current period expenditures, prior period expenditures, and expenditures per activity. During the audit period the School Corporation submitted two ESSER I reports, two ESSER II reports and two ESSER III reports, for a total of six reports. The annual data reports were prepared by the Treasurer. Due to the lack of effective internal controls one of the six annual data reports was not supported by the School Corporation’s records. For the ESSER III, Year 2 report, which covered the period of July 1, 2021 to June 30, 2022, total expenses per the report were $688,778. However, the School Corporation’s ledger had total expenses for the award, for that time period, of $784,638. The lack of controls and noncompliance were isolated to the ESSER III, Year 2 report. Contact Person Responsible for Corrective Action: Leslie Rittenhouse Contact Phone Number and Email Address: 765-395-3341 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As the finding and error occurred in one entry of one report the district will continue the practice of having a second party review financial system data against report entries. The error in this instance was a misunderstanding of the entry. A secondary review of reporting guidelines and entries will take place prior to submission of any ESSER Data Reporting. Anticipated Completion Date: Upon the next submission of ESSER Data reporting.

View Audit 367782

Finding 1155441 (2023-001)

Material Weakness 2023

Promedica Health System and Subsidiaries

OH

Reporting Questioned Costs Material Weakness § 200.502 § 200.508 § 200.510

Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: Management fully understands the importance of internal controls to ensure the schedule of federal expenditures is complete and accurate. The Grants Dep...

Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: Management fully understands the importance of internal controls to ensure the schedule of federal expenditures is complete and accurate. The Grants Department will amend its current written processes regarding award establishment to include requiring documentation indicating an award is federal funds prior to establishing the project in Infor CloudSuite Financials & Supply Management (Accounting software). Additionally, the Grants Department will routinely audit the database the department utilizes to record awards to ensure the field to note federal awards is properly updated. Furthermore, the SEFA will be reviewed with documented sign-off by each member of the Grants Team prior to submission. Contact person responsible for corrective action: Stephanie Cihon Anticipated Completion Date: October 31, 2025

View Audit 367737

Finding 1155310 (2023-016)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting Material Weakness

A standardized reconciliation process has been recated by our grant accountant to ensure all project and expenditure reports are aligned.

View Audit 367551

Finding 1155308 (2023-014)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Eligibility Reporting

The Maryland Departments of Human Services (DHS) and Housing and Community Development (DHCD) are the direct recipient of the federal funds for OHEP and WAP, respectively. Because of this, all verification occurs on the state level and HHS does not have access to all pertinent information. As the re...

The Maryland Departments of Human Services (DHS) and Housing and Community Development (DHCD) are the direct recipient of the federal funds for OHEP and WAP, respectively. Because of this, all verification occurs on the state level and HHS does not have access to all pertinent information. As the recipient of these funds, HHS is informed by DHS or DHCD when a Crisis Client is to be served by HHS. HHS is not responsible for the verification of Crisis Client eligibility for either program.

View Audit 367551

Finding 1155307 (2023-013)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Reporting Significant Deficiency

SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicate...

SharePoint is being utilized to track reporting requirements to ensure timely filings. The Department will continue to explore ways to streamline the process. However, final numbers for the prior month are typically not available until the second week after the close of the month. This is complicated by the need for controls in place to ensure the final numbers are correct.

View Audit 367551

Finding 1155304 (2023-010)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting

The Department has instituted a policy to maintain electronic back-ups of all documentation utilized to submit all federal reports. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission.

View Audit 367551

Finding 1155300 (2023-006)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting Subrecipient Monitoring Significant Deficiency

The Department has instituted a policy that FFRs must be submitted within 30 days of the end of the quarter. This will allow for any unforeseen circumstances that may delay submission.

View Audit 367551

Finding 1155298 (2023-004)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting

The Department has instituted a policy to maintain electronic back-ups of all documentation utilized in the submission of both the UDS and FFR. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission. Furthermore, the Healt...

The Department has instituted a policy to maintain electronic back-ups of all documentation utilized in the submission of both the UDS and FFR. The electronic copies are backed up on a SharePoint service. Additionally, the Finance Staff will review the FFR prior to submission. Furthermore, the Health Center has recently adopted a new EHR with UDS functionality built into the system allowing us to streamline submission.

View Audit 367551

Finding 1155297 (2023-003)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting Internal Control / Segregation of Duties

The finance department will review Form SF-425 compared to financial reports prior to submittals. Quarterly reminders have been initiated to ensure timely reporting moving forward.

View Audit 367551

Finding 1155295 (2023-008)

Material Weakness 2023

West Side Community Health Services INC

MN

Reporting Internal Control / Segregation of Duties § 200.303

2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/a...

2023-008 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend implementing a formal policy and procedure where there is a review of all required reporting by an individual that did not prepare the report. Documentation should be retained to support the review/approval occurrence. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a formal review process for reporting and retain documentation of review. This has been incorporated in subsequent reporting years. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025

View Audit 367533

Finding 1155294 (2023-007)

Material Weakness 2023

West Side Community Health Services INC

MN

Questioned Costs Reporting Significant Deficiency § 200.303

2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial...

2023-007 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend in the future the Organization retain documentation of key control processes occurring for a reasonable retention period to be able to support control activities around grant compliance and financial reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will retain timesheet documentation moving forward to support control process in place. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025

View Audit 367533

Finding 1155207 (2023-001)

Material Weakness 2023

Town of Granby

NY

Procurement, Suspension & Debarment Reporting Matching / Level of Effort / Earmarking

Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger...

Corrective Action Plan: To address this issue and prevent recurrence, the Town has implemented the following measures: 1. Reconciliation Procedures: Finance Department staff will reconcile all expenditures reported on USDA Form E – RD Project Budget/Cost Certification Reporting to the general ledger, ensuring both the accuracy of amounts and the correct vendor attribution. 2. Vendor Verification: A vendor cross-check process will be added to the review, requiring staff to match each reported expenditure to the appropriate invoice, purchase order, and vendor record before submission. 3. Review & Approval Controls: A supervisory review will be conducted prior to submission of Form E reports to verify vendor accuracy, in addition to ensuring no duplicate or misclassified expenditures are reported. The Town is committed to ensuring compliance with all USDA reporting requirements. By strengthening reconciliation, vendor verification, and review processes, we will reduce the risk of reporting errors and maintain accurate, reliable financial reporting moving forward.

View Audit 367451

Corrective Action Plans

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