Corrective Action Plans

Finding 1176727 (2021-001)

Material Weakness 2021

AK

Allowable Costs / Cost Principles Reporting

Chuloonawick Native Village agrees with the finding and will retain documentation supporting its expenditures for subsequent audits and train all new staff correct filing procedures.

View Audit 390654

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calcu...

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calculation was incorporated into the Period 4 PRF submission. To prevent recurrence, the Organization has strengthened its internal review protocols for reporting, including mandatory reconciliation of all revenue inputs to audited financial statements and secondary review by the Regional Controller prior to submission. These enhanced controls ensure that future lost revenue calculations are accurate, supportable, and compliant with HRSA reporting requirements.

View Audit 390602

Finding 1176707 (2021-004)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Defi...

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.

View Audit 390602

Finding 1176706 (2021-003)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Questioned Costs Cash Management

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology ...

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology with full underlying documentation in line with PRF reporting requirements.

View Audit 390602

Finding 1176174 (2021-003)

Material Weakness 2021

City of Chester

PA

Eligibility Material Weakness Reporting

The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklist...

The City agrees with the finding. Starting in the summer of 2024, procedures were implemented to begin monthly financial statements leading to being prepared for more timely year-end closings. These procedures included expenditure and revenue reports being prepared and reviewed, as well as checklists and reconciliations being prepared and reviewed. Retroactive review processes are underway regarding 2022 and 2023 years to be audited.

View Audit 389991

Finding 1171351 (2021-002)

Material Weakness 2021

Ekentucky Advanced Manufacturing Institute INC

KY

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022...

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022 by January 3 1, 2026. The information for audits of the subsequent years' financial statements will be submitted within 30 days of the completion of the prior year audit. The organization expects to be current on the audits and filings by December 31, 2027.

View Audit 384645

Finding 1170873 (2021-001)

Material Weakness 2021

RTC Industries, Inc.

OH

Questioned Costs Reporting § 200.512

Corrective Action Plan Agency: Department of Transportation, passed through Ohio Department of Transportation Audit Period: 2021 Audit Finding Number: 2021-01 Audit Finding Title: Noncompliance with Audit Submission Requirements Corrective Action Plan: Management concurs with the finding. Management...

Corrective Action Plan Agency: Department of Transportation, passed through Ohio Department of Transportation Audit Period: 2021 Audit Finding Number: 2021-01 Audit Finding Title: Noncompliance with Audit Submission Requirements Corrective Action Plan: Management concurs with the finding. Management has engaged a new audit service provider and has implemented plans to complete the required audits and submit the required Reporting package and Data Collection Forms. Anticipated Completion Date: With the hiring of new auditors, the corrective action plan is substantially completed even though the work is ongoing. Contact Person Responsible: Tina Burrey, Finance Director

View Audit 384180

Finding 1168971 (2021-002)

Material Weakness 2021

Alabama Rural Coalition for the Homeless INC

AL

Reporting

Management agrees with this finding. Management will take the appropriate actions to ensure that its Single Audit Reporting Package is submitted to the Federal Audit Clearinghouse no later than nine months after fiscal year end.

View Audit 381641

Finding 1168770 (2021-004)

Material Weakness 2021

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Questioned Costs Material Weakness Reporting

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 380881

Finding 1167847 (2021-003)

Material Weakness 2021

Northern Marianas Housing Corporation

FM

HUD Housing Programs Reporting

Corrective Action: NMHC will strengthen controls over compliance with applicable Uniform Financial Reporting Standards reporting requirements and the timely reconciliation of its general ledger accounts. NMHC will make sure to distinguish the reporting between the VMS and FDS for reporting purposes ...

Corrective Action: NMHC will strengthen controls over compliance with applicable Uniform Financial Reporting Standards reporting requirements and the timely reconciliation of its general ledger accounts. NMHC will make sure to distinguish the reporting between the VMS and FDS for reporting purposes only.

View Audit 379196

Finding 1165510 (2021-001)

Material Weakness 2021

New Directions, Inc.

CA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 376224

Finding 1165037 (2021-009)

Material Weakness 2021

Pima Council on Aging

AZ

Questioned Costs Material Weakness Reporting

Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler...

Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA has instituted an internal review and approval process for the Schedule of Expenditures of Federal Awards (SEFA), which now requires sign-off by the Finance Director prior to submission to the auditors.  The third-party accounting firm prepared and reconciled the SEFA in collaboration with internal staff  Technical hires are being made to ensure continued compliance and review capacity during year-end closing. Completion Date: July 31, 2025

View Audit 375125

Finding 1165036 (2021-008)

Material Weakness 2021

Pima Council on Aging

AZ

Questioned Costs Material Weakness Reporting

Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Directo...

Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA, with the assistance of DES, has created a grant compliance tracking system.  PCOA has also implemented oversight procedures to ensure all federal reports are submitted accurately and on time.  The Finance Director will assist in structuring these controls around the training program and finance staff.  The Finance Director oversees this process, and their capacity to do so has been strengthened through targeted hiring of experienced finance professionals.

View Audit 375125

Finding 1165031 (2021-003)

Material Weakness 2021

Pima Council on Aging

AZ

Allowable Costs / Cost Principles Cash Management Reporting

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting correcti...

Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting corrective action plan: Francine McGetrick, Contracts Director, Fmcgetrick@pcoa.org The corrective action plan: 1. PCOA has implemented procedures requiring internal review of all client sign-in sheets related to meals billed for reimbursement. 2. While the required sign-in documentation was completed and retained, it was stored in the contracts area and not submitted with the DES files. A new process has been established to ensure that sign-in sheets are filed along with the corresponding summary information at the time of submission. 3. PCOA has designed the updated process and trained staff to ensure proper documentation is verified prior to billing. 4. Ongoing compliance is now overseen by the Director of Contracts, and operational staff have been re-trained to ensure consistent execution. Completion Date: June 30th, 2025

View Audit 375125

Finding 1165030 (2021-002)

Material Weakness 2021

Pima Council on Aging

AZ

Questioned Costs Material Weakness Reporting

Finding Number 2021-002: – Late Filing of Uniform Guidance Audit, July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not file the Uniform Guidance Audit before the established deadline PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director,...

Finding Number 2021-002: – Late Filing of Uniform Guidance Audit, July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not file the Uniform Guidance Audit before the established deadline PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: Background: Prior to fiscal year 2021, PCOA consistently completed and submitted its Uniform Guidance audits on time. The delay in filing for fiscal year 2020–2021 was primarily due to a change in executive leadership, which significantly impacted internal capacity and oversight during that period. PCOA acknowledges the missed filing deadline and has since taken corrective action, including hiring a new Finance Director and engaging a third-party accounting firm to support the finance team during the transition and assist in bringing all outstanding audits current. These measures have been implemented to ensure timely and compliant audit submissions moving forward. 1. A finance compliance calendar has been established, and oversight of reporting deadlines will be completed by the newly hired Finance Director. 2. The third-party accounting firm supports timely preparation and review of audit materials. 3. New accounting staff are also being hired to ensure workload coverage and continuity during critical reporting periods. 4. In addition, ongoing training and cross-training of staff will continue under the direction of the Finance Director to strengthen internal capacity and mitigate future risks. Completion Date: June 30, 2025

View Audit 375125

Finding 1164837 (2021-001)

Material Weakness 2021

Olympic Medical Center

WA

Reporting § 200.512

November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the r...

November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the related complexities associated with the evolving guidance, it was challenging to prepare the Schedule of Expenditures of Federal Awards (SEFA) and related support completely and accurately for the single audit by the required due dates. Before the COVID-19 pandemic, grant expenditures related to federal programs rarely surpassed the single audit threshold, and the single audit threshold for OMC is unlikely to be surpassed in the future. To prepare for the possibility of future federal grant awards, all applications and contracts for federal awards will require review and approval by OMC's Contracts department. All applications for federal awards will be forwarded to the Chief Financial Officer for evaluation, acceptance, and record-keeping for Schedule of Expenditure of Federal Awards, SEFA. The recordkeeping for SEFA will be for accuracy, completeness, and reconciliation with accounting records. These records will support the performance of the single audit. OMC will implement this Corrective Action Plan effective November I,2025 Stillman Interim CFO Contracts Manager Controller cc

View Audit 374663

Finding 1164267 (2021-006)

Material Weakness 2021

Puerto Rico Emergency Management and Disasters Bureau

PR

Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.327 § 200.329

Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA...

Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA records, ensuring each report includes federal and recipient share, drawdown activity, and unliquidated obligations, designating an official responsible for report review and approval prior to submission with evidence of filing retained, and providing staff training on federal reporting requirements under 2 CFR 200.327–200.329 to improve accuracy, completeness, and compliance in federal financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

View Audit 373614

Finding 1164266 (2021-005)

Material Weakness 2021

Puerto Rico Emergency Management and Disasters Bureau

PR

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.302 § 200.328

Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports...

Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports include federal and recipient share, drawdown activity, and unliquidated obligations, designate responsible personnel for review and approval prior to filing with evidence of submission retained, and provide staff training on federal reporting requirements under 2 CFR 200.327–200.329 to strengthen compliance and accuracy in financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

View Audit 373614

Finding 1164265 (2021-004)

Material Weakness 2021

Puerto Rico Emergency Management and Disasters Bureau

PR

Reporting Procurement, Suspension & Debarment Subrecipient Monitoring § 200.510 § 200.511 § 200.512 § 200.515

Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required ...

Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required documentation, and coordinating with fiscal, program, and grants staff to ensure financial data, the SEFA, and supporting information are complete and ready within the Uniform Guidance deadline; PREMA will also assess staffing needs, implement procedures to track reporting progress, and provide training to personnel involved in the audit submission process. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

View Audit 373614

Finding 1164263 (2021-001)

Material Weakness 2021

Puerto Rico Emergency Management and Disasters Bureau

PR

Reporting Subrecipient Monitoring § 200.302 § 200.328

Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to en...

Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to ensure timely, accurate, and complete financial information for the Statement, SEFA, and required federal reports; PREMA will also evaluate staffing needs, provide training on PRIFAS and federal reporting requirements, and conduct periodic reviews to ensure compliance with reporting deadlines and data accuracy. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.

View Audit 373614

Finding 1163085 (2021-002)

Material Weakness 2021

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...

Audit Finding: Finding 2021-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately

View Audit 372661

Finding 1163015 (2021-008)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1163014 (2021-007)

Material Weakness 2021

Ruth Ellis Center, Inc.

MI

Questioned Costs Subrecipient Monitoring Material Weakness § 200.303

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...

View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.

View Audit 372604

Finding 1162823 (2021-012)

Material Weakness 2021

Chester Upland School District

PA

Questioned Costs Reporting

Finding 2021-012 - Repeat of 2020-009; Reporting Description of Finding: The School District reports related to several grants were either filed late or not at all. The accuracy of the reports that were filed could not be determined, as the supporting documentation or reconciliations for the amounts...

Finding 2021-012 - Repeat of 2020-009; Reporting Description of Finding: The School District reports related to several grants were either filed late or not at all. The accuracy of the reports that were filed could not be determined, as the supporting documentation or reconciliations for the amounts disclosed in the report were not complete. District Position: The School District concurs with the finding. Corrective Action to be Taken: The District has appointed a Federal Programs Coordinator who is familiar with the Single Audit requirements of the Uniform Guidance. Management and the Federal Programs Coordinator have implemented policies and procedures to identify grant reporting due dates and identify relevant grant information and source documentation need to for reporting requirements. The Federal Programs Coordinator reviews grant reporting filing deadlines on a regular basis and reconciles source documentation to the general ledger in the accounting software with Business Office management prior to filing quarterly and final expenditure reports. Timetable for Implementation: Implemented for 2022-2023 fiscal year Monitoring to be Performed: The Receiver and Business Manager will monitor timely and continued implementation. Responsible Person with Scope of Authority: Receiver and Business Manager

View Audit 372470

Finding 1162314 (2021-003)

Material Weakness 2021

Levee Road Water Association, Inc.

KY

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

The Association concurs with the recommendation. The Association has implemented a new procedure to ensure that any future reporting compliance requirements related to the expenditure of federal funds are completed on a timely basis.

View Audit 372132

Corrective Action Plans

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