Corrective Action Plans

Finding 573007 (2024-003)

Material Weakness 2024

AZ

Cash Management Material Weakness Reporting

Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement:...

Item: 2024-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Reporting Criteria or Specific Requirement: Per the grant agreements, award recipients are required to submit monthly reimbursement report within a set number of days after month end. Condition: Financial reimbursement reports were submitted after the required due date. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will submit required reports timely going forward.

View Audit 363873

Finding 573006 (2024-002)

Material Weakness 2024

Southwest Center for Hiv/aids, INC

AZ

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.405

Item: 2024-002 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or ...

Item: 2024-002 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

View Audit 363873 Questioned Costs: $1

Finding 573005 (2024-001)

Material Weakness 2024

Southwest Center for Hiv/aids, INC

AZ

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.405

Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or...

Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

View Audit 363873 Questioned Costs: $1

Finding 572982 (2024-001)

None 2024

Catholic Family Services D/b/a Catholic Charities Diocese of Kalamazoo

MI

Reporting

Recommendation: We recommend that the Organization establish controls to ensure the accuracy of the reporting of enrollee service days, as well as instituting a review process to catch any potential errors prior to submission. Management Response: The Organization has reviewed its procedure for ensu...

Recommendation: We recommend that the Organization establish controls to ensure the accuracy of the reporting of enrollee service days, as well as instituting a review process to catch any potential errors prior to submission. Management Response: The Organization has reviewed its procedure for ensuring the days of care recorded match the days of Service submitted for the monthly substantiation reports. We have addressed this matter in two ways. We have re-trained staff as to the requirements of the State of Michigan and how to calculate and record days of care for youth residing at the Ark. Additionally, we will have both our Compliance Officer and Data Analyst review the files and days of care tabulation to ensure accuracy in the submission of days of care to Michigan Department of Health and Human Services (“MDHHS”).

View Audit 363852

Finding 572971 (2024-002)

Material Weakness 2024

City of Marshalltown

IA

HUD Housing Programs Material Weakness Reporting § 200.303

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified i...

Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified in which the City did not use accurate financial information or retain evidence to document the individual who reviewed the Voucher Management System (VMS) reports prior to submission. Responsible Individual: Diana Steiner, Finance Director Corrective Action Plan: We agree with the auditor’s recommendation and staff will have asecond person review the reports. Anticipated Completion Date: By the completion of the ACFR for the fiscal year ending June 30, 2025.

View Audit 363814

Finding 572970 (2024-003)

Material Weakness 2024

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

Reporting

Since the Agency began receiving the Notice of Awards under the new entity in May 2024, we continue to submit the SF-270 in a timely manner for the awarding agency's approval, in accordance with our Standard Operating Procedures (SOPs) and as required by regulations.Proposed Completion Date: Decembe...

Since the Agency began receiving the Notice of Awards under the new entity in May 2024, we continue to submit the SF-270 in a timely manner for the awarding agency's approval, in accordance with our Standard Operating Procedures (SOPs) and as required by regulations.Proposed Completion Date: December 31, 2025

View Audit 363810

Finding 572969 (2024-002)

Material Weakness 2024

Oficina De Proteccion Y Defensa De Las Personas Con Impedimentos

PR

Reporting

The O􀆯ice is sending the 270 monthly in compliance with applicable regulations and as established in our SOP since October 2024, the date the grantee gave us the approval for submitting all the 270. Proposed Completion Date: December 31, 2025

View Audit 363810

Finding 572963 (2024-001)

None 2024

Beacon Health System, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.

View Audit 363788

Finding 572940 (2024-002)

Significant Deficiency 2024

Presbyterian Medical Services

NM

Reporting Significant Deficiency Internal Control / Segregation of Duties

Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, D...

Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, Director of Finance. Estimated Completion Date: May 15, 2025

View Audit 363780

Finding 572933 (2024-001)

None 2024

City of Webster Groves

MO

Reporting Internal Control / Segregation of Duties

2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporti...

2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan The employee responsible for this negligence no longer works for the City. The City will endeavor to comply with all reporting requirements for our Federal Grants and monies received. Responsible Person for Corrective Action Plan Gregory Donovan, Director of Finance (SLFRF) Tenille Rose Martin, Grants Manager (SS4A) Elliot Liebson, Director of Planning (FEMA) Gary Bainter, Asst. Fire Chief (FEMA) Implementation Date of Corrective Action Plan January 1, 2025

View Audit 363772

Finding 572657 (2024-002)

Significant Deficiency 2024

Mayo Clinic

MN

Subrecipient Monitoring Reporting

Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews ...

Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews are current. Persons Responsible for Corrective Action Susan Norby, Division Chair - Research Finance Completion Date March 31, 2025

View Audit 363769

Finding 572655 (2024-001)

None 2024

Mercy Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the audito...

Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

View Audit 363760

Finding 572646 (2024-001)

Significant Deficiency 2024

The Harbour Inc.

IL

Reporting

The Organization will submit the current year audit reporting package and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2025.

View Audit 363745

Finding 572630 (2024-002)

Significant Deficiency 2024

Housing Authority of the City of Tampa, Florida

FL

Questioned Costs HUD Housing Programs Cash Management § 200.302 § 200.305

Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Office...

Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Officer with over 30 years of public housing experience was hired by the agency in April of 2024. The CFO has fully staffed the department with competent and qualified individuals including a new and fully qualified Controller and Director of Finance. All individuals hired have received targeted training from both internal and external sources. In June 2024 the new financial management team implemented a policy/procedure for the records requirement and payment timeframes for all capital fund draw downs. This policy requires the hand signing of eLOCCS forms and reconciliation of individual draws at the time of drawdown. During fiscal 2025 the entire Finance staff was trained extensively on all matters related to HUD accounting. Specific training was directed to the Capital Fund program, its eligibility standards, accounting processes, and drawdown procedures. This training was conducted by a nationally recognized HUD-specific trainer. The Authority has hired a qualified, experienced internal auditor. The internal auditor has completed a 100% testing sample on capital fund draws made in fiscal 2025. His observations were rectified, and the policy revised where needed. The sampling assured that supporting documentation was sufficient for audit, that it matched the amounts drawn, and that invoices were paid within HUD dictate s timeframes. Management feels that with this policy and enhanced testing in place the finding will not be repeated in 2025. Management expects closure of this finding, under the direction of the Chief Financial Officer, for the Fiscal 2025 audit.

View Audit 363741 Questioned Costs: $1

Finding 572623 (2024-003)

Significant Deficiency 2024

Del Norte Child Care Council

CA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.512

Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the d...

Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to provide financial oversight. Action: Develop procedures to ensure required single audits are completed and submitted to the Federal Audit Clearinghouse by the 9-month due date. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director Carrie Castillo, Executive Director, is the official responsible for implementing each corrective action plan.

View Audit 363736

Finding 572622 (2024-002)

Material Weakness 2024

Del Norte Child Care Council

CA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being up...

Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director

View Audit 363736

Finding 572589 (2024-004)

Material Weakness 2024

Decatur County

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Christy Smiley Contact Phone Number and Email Address: 812-663-2570, auditor@decaturcounty.in.gov Views of Responsible Officials: We concur with ...

FINDING 2024-004 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Christy Smiley Contact Phone Number and Email Address: 812-663-2570, auditor@decaturcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: INDIANA STATE BOARD OF ACCOUNTS 27 At least 2 people will look over the report and check all receipts and expenditures when the next P&E report is submitted to prevent and detect any errors. Prior P&E report had already been submitted before the prior audit was complete and we were made aware of the issue and then the Auditor changed in 2025. Control will not be in place until the 2026 P&E report is submitted. Anticipated Completion Date: Submission of next ARPA report, April 2026.

View Audit 363722

Finding 572552 (2024-001)

Material Weakness 2024

Grand Prairie Services

IL

Reporting

Finding Reference Number: 2024-01 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the audited financial statements, schedule of expenditures of federal awards, ...

Finding Reference Number: 2024-01 View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will establish procedures and monitor compliance with those procedures to ensure that the audited financial statements, schedule of expenditures of federal awards, and other required information is filed with the Federal Audit Clearinghouse by the required due dates. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Completion Date: Open

View Audit 363702

Finding 572519 (2024-004)

Significant Deficiency 2024

Madison Parish Police Jury

LA

Procurement, Suspension & Debarment Reporting Equipment & Real Property Management

Reference # and title: 2024-004 Reporting Federal Grantor/Program Name Assistance Listing No. Award Year State & Local Fiscal Recovery Funds (ARPA) 21.027 2021 Criteria or specific requirement: The Police Jury is required to submit a project and expenditure report quarterly and annually. The ke...

Reference # and title: 2024-004 Reporting Federal Grantor/Program Name Assistance Listing No. Award Year State & Local Fiscal Recovery Funds (ARPA) 21.027 2021 Criteria or specific requirement: The Police Jury is required to submit a project and expenditure report quarterly and annually. The key line items in the report are obligations and expenditures. Condition found: The report submitted in March 2025 for the period ended December 31, 2024, did not agree with documentation for the Desoto Street Project and the Public Works Equipment project. The Desoto Street Project reported $300,000 in total cumulative obligations and $300,000 in total cumulative expenditures. The project was complete on December 31, 2024, for a total cost of $77,528. Both the cumulative obligations and expenditures were overstated $222,472. The Public Works Equipment project total cumulative obligations were reported as $289,426 and total cumulative expenditures were reported as $220,000. The equipment was purchased for $220,000. The cumulative expenditures agree to the supporting documentation, but the cumulative obligations are overstated by $69,426. The report did not include documentation that it was reviewed by anyone other than the preparer. Context: The December 31, 2024, report filed in March 2025 was tested by comparing amounts reported for cumulative obligations and expenditures to support for cumulative obligations and expenditures. Possible asserted effect (cause and effect): Cause: There is no evidence that the report was reviewed for errors by someone other than the preparer. Effect: The Police Jury may have unobligated amounts of $291,898 on December 31, 2024, which was the last day to obligate the funds. Recommendation to prevent future occurrences: The Policy Jury should communicate with the grantor agency to determine if the amount that is not obligated per the report should be repaid. Origination date and prior year reference (if applicable): This finding originated in the current fiscal year. Corrective action planned: Management will confer with the grantor to verify if repayment is due because of the error.

View Audit 363683

Finding 572518 (2024-003)

Significant Deficiency 2024

Madison Parish Police Jury

LA

Reporting

Reference # and title: 2024-003 Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Federal Grantor/Program Name Assistance Listing No. Award Year State & Local Fiscal Recovery Funds (ARPA) 21.027 2021 Criteria or specific requirement: The Police Jury is required to have a compr...

Reference # and title: 2024-003 Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Federal Grantor/Program Name Assistance Listing No. Award Year State & Local Fiscal Recovery Funds (ARPA) 21.027 2021 Criteria or specific requirement: The Police Jury is required to have a comprehensive and accurate schedule of expenditures of federal awards (SEFA) to document federal grant expenditures by agency, program and amount. Condition found: The Police Jury did not submit a complete and accurate SEFA. Context: The SEFA prepared by the Police Jury did not list the Federal granter, Program title, Federal ALN numbers, and Grant numbers. Federal awards were either missing from the SEFA or listed in incorrect amounts. Possible asserted effect (cause and effect): Cause: The Police Jury does not have processes and procedures documented for preparing a SEFA. Effect: The Police Jury may not meet all federal compliance requirements. Recommendation to prevent future occurrences: The Police Jury should document processes and procedures for preparing a schedule of expenditures of federal awards (SEFA). Origination date and prior year reference (if applicable): This finding originated in the current fiscal year. Corrective action planned: Management will provide and prepare the required information in the requested format.

View Audit 363683

Finding 572516 (2024-002)

Significant Deficiency 2024

City of Peoria, Illinois

IL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

The City’s Finance Department is working with the Fire Department to install the proper internal controls over the preparation of the performance reports. Going forward, the reports that are prepared by the City’s Fire Chief will be reviewed by the City’s Finance Department to ensure accuracy and co...

The City’s Finance Department is working with the Fire Department to install the proper internal controls over the preparation of the performance reports. Going forward, the reports that are prepared by the City’s Fire Chief will be reviewed by the City’s Finance Department to ensure accuracy and compliance.

View Audit 363673

Finding 572510 (2024-006)

Significant Deficiency 2024

Second Harvest Community Foodbank

MO

Cash Management Reporting

We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently developing an appropriate cost allocation plan which will address direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Throug...

We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently developing an appropriate cost allocation plan which will address direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a spreadsheet will be developed to better distribute costs appropriately across all federal programs operated by Second Harvest and efforts supported through additional funding sources. This corrective action will be implemented by October 1, 2025.

View Audit 363656

Finding 572481 (2024-003)

Significant Deficiency 2024

City of Boynton Beach

FL

Allowable Costs / Cost Principles Reporting § 200.512

SD2024-003 - Reporting - Data Collection Form ...

SD2024-003 - Reporting - Data Collection Form Management acknowledges the finding. Due to significant finance leadership turnover, the city lagged in audit reporting. The new Finance Director, who started on February 28th, 2025, reviewed the audit status in mid-March. The Finance Director hired an experienced Divisional Director, who took over the audit in late April. The newly implemented Month-End closed process will address any reporting issues and ensure compliance with the Florida State Statute. Additionally, the city will begin the year-end audit process each November of the following fiscal year.

View Audit 363619

Finding 572480 (2024-006)

Significant Deficiency 2024

City of Clinton, Iowa

IA

Subrecipient Monitoring Reporting

The City will ensure that federal funding awards are reported on the FFTA website.

View Audit 363616

Finding 572479 (2024-005)

Significant Deficiency 2024

City of Clinton, Iowa

IA

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

The City will start requireing all supporting documentation for all grants, including those administered by a third party.

View Audit 363616

Corrective Action Plans

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