Corrective Action Plans

Finding 1209130 (2024-120)

Material Weakness 2024

State of Arizona

AZ

Special Tests & Provisions Procurement, Suspension & Debarment Cash Management

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS...

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.

View Audit 399861

Finding 1209115 (2024-108)

Material Weakness 2024

State of Arizona

AZ

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Chil...

Assistance listing numbers and program names: 93.575 Child Care and Development Block Grant 93.575 COVID-19 Child Care and Development Block Grant 93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund 93.596 COVID-19 Child Care Mandatory and Matching Funds of the Child Care and Development Fund Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will review, correct, and /or complete any incomplete or inaccurate information for its subawards on the Federal Funding Accountability and Transparency Act Subaward Reporting System. The Department will follow the State’s accounting manual for reporting subaward actions equaling or exceeding $30,000 no later than month-end of the month following the subaward action. The Department has implemented procedures that ensure that the contracts team communicates all new contracts and contract amendments in the APP.

View Audit 399861

Finding 1209098 (2024-112)

Material Weakness 2024

State of Arizona

AZ

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency R...

Assistance listing numbers and program names 84.010 Title I Grants to Local Education Agencies 84.367 Supporting Effective Instruction state Grants, Title II (formerly Improving Teacher Quality State Grants) 84.425D COVID-19 – Education Stabilization Fund –Elementary and Secondary School Emergency Relief (ESSER) 84.425U COVID-19 – Education Stabilization Fund – American Rescue Plan – Elementary and Secondary School Emergency Relief (ARP-ESSER) Agency: Arizona Department of Education (ADE) Name of contact person and title: Matthew McClary, Grants Management Compliance Officer Nicole von Prisk, Deputy Associate Superintendent Anticipated completion date: October 2027 Agency’s Response: Concur The Arizona Department of Education has worked in cooperation with our vendor to correct outdated SQL queries that were identified and return only approved grant award amounts rather than all awarded amounts, regardless of approval status. This issue was causing several subaward amounts to incorrectly update. Moving forward, we are ensuring that the original award amounts are being queried and, in return, reported within SAM.gov (System for Award Management). Additionally, through the reconciliation process each month, correct award amounts will align with the corresponding Federal Award Identification Number (FAIN). Reports being submitted late: We have implemented an automated monthly reporting workflow/schedule which will help ensure required FFATA reporting is submitted timely. This process automation helps prompt monthly FFATA reporting uploads by leveraging office tools that are readily available and ensures monthly upload deadlines are met by automatically scheduling the task and requiring follow-up by the assignee. In January of 2024, the staff assigned to FFATA uploads changed again (for the fourth time in a year) and at that point a new staff member assumed responsibility for FFATA uploads. As numerous corrections needed were discovered through the reconciliation process, new reports were uploaded. Some of these were original uploads for entities that were missing SAM.gov (formerly FSRS) information altogether, and some were corrections to previously uploaded yet incorrect information. With each monthly upload, a new date was being captured and while some of the information was new entity award information, not all the information being updated was untimely. This has been a long and arduous process, and we look forward to not having continued FFATA findings, as we are making progress to correct award information for all federal grants moving forward from this point. Inaccurate and/or Incomplete Data: Our Compliance Officer conducts a monthly reconciliation of current SAM.gov award information in coordination with either the Lead Grants Coordinator or the Deputy Associate Superintendent. During this review, any missing, inconsistent, or duplicate data is identified and corrected prior to the upload into SAM.gov. Once the subawards have been uploaded, the reconciliation process is repeated to verify the accuracy of the information recorded within SAM.gov. Note: On October 30, 2025, we became aware that USASpending.gov was no longer updating subawards to correspond with the data we have submitted in SAM.gov. We raised a service desk ticket to USA Spending (Case 00089604), but the issue is ongoing. USA Spending has stated that they “are aware of an issue with the outbound API in SAM to USA Spending, but due to the lapse in funding, the SAM team working on this specific issue has been furloughed until funding is restored.” The reconciliation process where subawards uploaded to SAM.gov are compared to the data in USASpending.gov continues to be heavily impacted until this service is restored. To ensure accurate documentation and timely resolution of system related challenges encountered when submitting subawards in SAM.gov, the Compliance Officer has implemented a formal Incident Tracking process. All technical issues are logged at the time they occur, and each incident is subsequently submitted to the Federal Service Desk (FSD.gov). Upon submission, the incident is assigned an official Incident Request ID along with a corresponding date and time stamp, enabling effective monitoring and follow‑up. Grants Management will establish, implement, and enforce internal and external controls to ensure that risk is minimized and can be appropriately evaluated during any monitoring conducted by the agency. The internal and external controls that will be implemented will establish guidelines addressing conflicts of interest, related-party transactions, and insufficient segregation of duties. Implementation will be based on reference materials provided by the U.S. Department of Education Office of Inspector General, as well as technical assistance from organizations with legal and governmental expertise. ADE’s software will be updated appropriately.

View Audit 399861

Finding 1209083 (2024-103)

Material Weakness 2024

State of Arizona

AZ

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipat...

Assistance listing number and program name: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Agency: Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Ben Henderson, Director Governor’s Office of Strategic Planning & Budgeting Anticipated completion date: December 31, 2026 Agency’s Response: Concur The Office agrees with this finding and will continue to take corrective action to bring the program fully into compliance with Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Federal grant reporting requirements. The Office recognizes the importance of transparency in the use of Federal grants and has taken significant corrective action to resolve any inaccuracies in Federal grant reporting. The Office has implemented specific actions to ensure reporting inaccuracies and program expenditure understatements/overstatements do not occur. During fiscal year 2025 and 2026, the Office has taken corrective action to improve SLFRF reporting processes, including conducting weekly reviews and monthly reconciliations as outlined: ● Award Reconciliation — The Office has conducted a comprehensive review and extensive reconciliation of all awards to identify reporting inaccuracies. This reconciliation will continue as an ongoing process through the SLFRF closeout. ● Expenditure Reconciliation — The Office staff responsible for preparing the SLFRF quarterly reports is completing the reconciliation of all expenditures to the State’s accounting records, which are the official expenditures for the program. This will continue as an ongoing process through the SLFRF closeout. ● Enhanced Reporting Mechanisms—The Office will review, correct, and/or resubmit any inaccurately reported information. The staff responsible for preparing the SLFRF quarterly reports is no longer reconciling to the Office’s internal grants-management system. Reports will be compiled from the State’s accounting records, which are the official record of expenditures made for the program. The Office will investigate and resolve any differences prior to submitting the report to the federal agency. This will continue as an ongoing process through the SLFRF closeout. ● Update Procedures—Based on the comprehensive review noted in the response above, the Office is continuing to implement improved reporting procedures to ensure the accurate submission of grant expenditure data. This includes revised standardized templates, improved guidelines, and enhanced communication channels to improve reporting accuracy. ● Ongoing Training — Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of reporting errors. During fiscal years 2025 and 2026, staff engaged in 18 professional development opportunities, including monthly federal reporting calls, grants management webinars and trainings, internal training sessions, state accounting system training, and participation in a Microsoft data conference. These ongoing efforts reflect our commitment to staying current with compliance requirements and best practices. The Office will continue to strengthen internal controls to prevent similar issues in the future. This involves strengthening oversight, providing additional training to staff members in reporting processes, and implementing regular quality assurance checks. As of this date, the Office has allocated sufficient resources to comply with the award terms and program reporting requirements by establishing the Grants Technology and Data team dedicated to overseeing the necessary SLFRF program reporting procedures. The Office is committed to eliminating any risk through a full reconciliation of expenditures by the end of the program, which occurs during fiscal year 2027.

View Audit 399861

Finding 1208927 (2024-106)

Material Weakness 2024

State of Arizona

AZ

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.334

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: C...

Assistance listing number and program name: 21.023 COVID-19 Emergency Rental Assistance Program Agency: Department of Economic Security (DES) Name of contact person and title: Molly Bright, Community Services Division Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: The Department will prepare and retain detailed documentation, including system reports, queries, screenshots, and other evidence, to support the program information reported to the federal agency for each Emergency Rental Assistance Program (ERAP) award. DES will also abide by its ERAP policies and procedures to retain all records related to the award for a period of 5 years after all federal funds are expended. The Department sunset the ERAP program on October 13th, 2023, due to an exhaustion of ERA 1 and ERA 2 funding.

View Audit 399861

Finding 1208873 (2024-003)

Material Weakness 2024

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Reporting Special Tests & Provisions

2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economi...

2024-003 - (Noncompliance) Completion of Single Audit Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000073444, C000075689, C000082264, C000086078, and PEMA-2022-007 Condition/Context: The County’s December 31, 2023 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Views of Responsible Officials and Planned Corrective Actions: Management understands and is working to better anticipate the needs and timing and availability of staff/information to complete the audit. The County has a third party that compiles the information to give to the auditors for auditing. The County is hoping with this that the information being audited will be timelier to get the audit completed.

View Audit 399816

Finding 1208851 (2024-002)

Material Weakness 2024

City of Bloomington

IN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficienc...

Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency, Noncompliance Condition: City of Bloomington completed quarterly reporting in a timely manner. However, the reports did not have evidence of segregation of duties and the cumulative expenses stated on the report did not agree to the cumulative expenditures reported on previous SEFAs. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report cumulative expenditures for the grant that were consistent with the expenditures reported on the SEFA. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has already implemented a policy effective third quarter of 2025 to ensure a documented two-person review process and reconciliation of costs to the report. Responsible party and timeline for completion: The Controller is responsible for overseeing the implementation of the corrective action plan and will ensure the appropriate personnel are involved in the review and reconciliation process. The corrective action plan has already been implemented effective for the third quarter of 2025.

View Audit 399810

Finding 1208819 (2024-002)

Material Weakness 2024

California Consortium for Urban Indian Health, Inc.

CA

Reporting § 200.512

The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the finding related to the late completion of the FY 2024 A‐133 audit. The delay resulted from administrative transitions and staffing challenges within the Finance Department du...

The California Consortium for Urban Indian Health (CCUIH) respectfully submits this corrective action plan in response to the finding related to the late completion of the FY 2024 A‐133 audit. The delay resulted from administrative transitions and staffing challenges within the Finance Department during the audit period. These circumstances affected the timely preparation of required schedules, supporting documentation, and responses to auditor requests. CCUIH has taken the following corrective actions to address the issue: · All FY 2024 audit requirements have now been completed and submitted. · Internal processes for audit preparation have been reviewed to identify gaps and inefficiencies. To prevent recurrence, CCUIH will implement the following measures: · Establish a revised annual financial reporting and audit preparation calendar with clearly defined internal deadlines. · Cross‐train finance staff to ensure continuity during staffing transitions or absences. · Strengthen oversight procedures for audit readiness, including periodic internal check‐ins leading up to the audit period. · Develop written procedures outlining roles, responsibilities, and timelines for audit preparation. The anticipated completion date for all corrective actions is June 30, 2026. The parties responsible for implementing and monitoring this corrective action plan are: · Kescia Turner, Director of Finance · Jennifer Ruiz, Executive Director

View Audit 399703

Finding 1208808 (2024-001)

Material Weakness 2024

Christina Cultural Arts Center, Inc.

DE

Reporting Subrecipient Monitoring § 200.510 § 200.515 § 200.516 § 200.518

Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.029 Cause: Controls over SEFA preparation and federal award identification were not sufficient to ensure all pass-through federal awards (including ARPA CPF) were captured with required identifiers (federal agency, ALN 21.029, p...

Coronavirus State and Local Fiscal Recovery – Assistance Listing No. 21.029 Cause: Controls over SEFA preparation and federal award identification were not sufficient to ensure all pass-through federal awards (including ARPA CPF) were captured with required identifiers (federal agency, ALN 21.029, pass-through name/number) before year-end reporting. Effect: An initially incomplete SEFA increases the risk that major programs are not properly identified for testing, which could result in modification of opinion due to incomplete SEFA, which ultimately could result in a delayed audit. Recommendation: We recommend CCAC implement and document SEFA preparation controls to ensure completeness and accuracy over maintaining a central grant repository containing award documents with federal agency, performing year-end SEFA reconciliation, and obtaining written ALN/FAIN confirmations from pass-through entities for any awards lacking federal identifiers and retaining those confirmations in the grant file. Views of Responsible Officials: There is no disagreement with the audit finding. See below for actions taken to remedy the finding. Management Response: Christina Cultural Center experienced a SEFA completeness finding during a year with bookkeeping turnover, which affected the initial compilation of federal award activity. In response, management worked closely with the audit team to confirm the complete listing of awards, validate pass-through entity details, and support accurate SEFA presentation. The organization has also identified cross-training as a key next step to strengthen continuity and reduce key-person dependency going forward.

View Audit 399681

Finding 1208804 (2024-008)

Material Weakness 2024

Metra - Commuter Rail Division & Commuter Railroad Corporation

IL

Subrecipient Monitoring Reporting Significant Deficiency § 200.511 § 200.512

Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submi...

Finding Reference: 2024-008 Finding Title: Noncompliance and Significant Deficiency, Data Collection Form CAP Contact Persons: • John Morris, Chief Financial Officer, Financial Affairs, (312) 322-6420 • Joseph Psioda, Controller, Financial Affairs, (312) 322-6346 Planned Corrective Actions: 1. Submission of Federal Reporting Package: Management will implement procedures to ensure the timely completion and submission of the annual audit, reporting package, and data collection form. This will include establishing a detailed audit timeline with interim milestones, strengthening coordination among departments responsible for required data and information, and proactively monitoring federal reporting deadlines. Management will also develop contingency plans to address delays in complex audit areas to minimize the risk of future reporting delays. These procedures will be implemented for the 2025 audit cycle to ensure timely submission to the Federal Audit Clearinghouse. Anticipated Completion Date: 06/30/2026

View Audit 399665

Finding 1208624 (2024-006)

Material Weakness 2024

Jefferson Parish

LA

Reporting Subrecipient Monitoring HUD Housing Programs

Management acknowledges this repeat finding and recognizes that, while prior conditions contributed to the issue, corrective actions have been implemented and significant progress has been made to resolve the finding. Since the audit finding, required compliance reports have been submitted timely. M...

Management acknowledges this repeat finding and recognizes that, while prior conditions contributed to the issue, corrective actions have been implemented and significant progress has been made to resolve the finding. Since the audit finding, required compliance reports have been submitted timely. Management considers the issue resolved; however, monitoring procedures will remain in place as a precaution to ensure continued compliance. Chief Administrative Assistant Nicole Thompson and Community Development Director Stephanie Brumfield will continue to monitor the submission of timely reports in compliance with federal requirements.

View Audit 399587

Finding 1208623 (2024-005)

Material Weakness 2024

Jefferson Parish

LA

Procurement, Suspension & Debarment Reporting Subrecipient Monitoring

Management acknowledges this repeat finding and the importance of full compliance with federal reporting requirements. While progress has been made, additional monitoring is still necessary to fully remediate this issue. As part of these efforts, Jefferson Parish, has established a process to monito...

Management acknowledges this repeat finding and the importance of full compliance with federal reporting requirements. While progress has been made, additional monitoring is still necessary to fully remediate this issue. As part of these efforts, Jefferson Parish, has established a process to monitor the timely submission of reports in compliance with federal requirements. Management considers the corrective action to be substantially implemented. Ongoing review has been put into place to confirm continued compliance. Chief Administrative Assistant Nicole Thompson will continue to monitor the submission of timely reports in compliance with federal requirements.

View Audit 399587

Finding 1208594 (2024-003)

Material Weakness 2024

Vernon J. Harris East End Community Health Center

VA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Management will establish a formal reconciliation process between the general ledger and all federal reports prior to submission. This will include documented review procedures, supervisory approval, and the use of standardized reconciliation templates. Staff will be trained on reporting accuracy re...

Management will establish a formal reconciliation process between the general ledger and all federal reports prior to submission. This will include documented review procedures, supervisory approval, and the use of standardized reconciliation templates. Staff will be trained on reporting accuracy requirements, and periodic internal reviews will be conducted to ensure financial data integrity and compliance.

View Audit 399556

Finding 1208593 (2024-002)

Material Weakness 2024

Vernon J. Harris East End Community Health Center

VA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Management will implement a centralized compliance tracking system that includes a reporting calendar with automated reminders for all federal reporting deadlines. Responsibility for report preparation and submission will be formally assigned, with supervisory review prior to submission. Compliance ...

Management will implement a centralized compliance tracking system that includes a reporting calendar with automated reminders for all federal reporting deadlines. Responsibility for report preparation and submission will be formally assigned, with supervisory review prior to submission. Compliance meetings will be established to monitor reporting status and ensure deadlines are met.

View Audit 399556

Finding 1208588 (2024-002)

Material Weakness 2024

San Diego Workforce Partnership

CA

Subrecipient Monitoring HUD Housing Programs Reporting

Effective March 1, 2026, the San Diego Workforce Partnership will incorporate the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System (FSRS) reporting deadline into the Month‑End Schedule. The activities outlined in this schedule help ensure that all required financ...

Effective March 1, 2026, the San Diego Workforce Partnership will incorporate the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System (FSRS) reporting deadline into the Month‑End Schedule. The activities outlined in this schedule help ensure that all required financial data is captured, reviewed, and reported in a timely and complete manner. The Accounting Manager will oversee the operational steps required to meet FSRS reporting deadlines, while the Chief Financial Officer (CFO) will provide overall oversight to ensure that these procedures are consistently followed and that internal control expectations are met. Effective March 1, 2026, to address the delay in submission of monthly reports for the ARPA grant to the pass-through agency, the San Diego Workforce Partnership is implementing strengthened internal controls and workflow procedures to ensure all required reports are submitted by the 15th day following the end of each month, as stipulated in the grant agreement.

View Audit 399554

Finding 1208582 (2024-001)

Material Weakness 2024

TOWN OF LOCKHART

SC

Reporting Significant Deficiency Internal Control / Segregation of Duties

Significant Deficiency 2024-001 – Internal Control Over Financial Reporting Name of Contact Person: Helen McFalls, Town Clerk Corrective Action: The Town is committed to taking steps to improve its financial management and accounting capacity and the Council will remain involved in the financial aff...

Significant Deficiency 2024-001 – Internal Control Over Financial Reporting Name of Contact Person: Helen McFalls, Town Clerk Corrective Action: The Town is committed to taking steps to improve its financial management and accounting capacity and the Council will remain involved in the financial affairs of the Town to provide oversight. Proposed Completion Date: Management has implemented the above action.

View Audit 399545

Finding 1208392 (2024-010)

Material Weakness 2024

City of Danbury

CT

Reporting Subrecipient Monitoring Eligibility § 200.512

Finding 2024-010 Material Weakness in Internal Control and Noncompliance, Late Issuance of the 2024 Single Audit Reporting Package to the Federal Audit Clearinghouse: Condition: The Single Audit packages for the City’s fiscal years ended June 30, 2024, June 30, 2023 and June 30, 2022 should have bee...

Finding 2024-010 Material Weakness in Internal Control and Noncompliance, Late Issuance of the 2024 Single Audit Reporting Package to the Federal Audit Clearinghouse: Condition: The Single Audit packages for the City’s fiscal years ended June 30, 2024, June 30, 2023 and June 30, 2022 should have been submitted to the Federal Audit Clearinghouse by March 31, 2025, March 31, 2024 and March 31, 2023, respectively. The City missed the filing deadlines, making the filings for 2024, 2023 and 2022, late. Contact Person: Daniel Garrick, Director of Finance Corrective Actions Planned: We agree with the finding. The City and Danbury Public Schools have made the audits a top priority by filling vacant positions and hiring an audit consulting firm. The 2025 audit is in process and we anticipate that the 2026 audit will be completed in a timely manner. Anticipated Completion Date: March 31, 2027

View Audit 399363

Finding 1208387 (2024-012)

Material Weakness 2024

City of Danbury

CT

Reporting Subrecipient Monitoring Significant Deficiency

Finding 2024-012 Significant Deficiency and Noncompliance Finding, Reporting – Special Reporting Condition: For the Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs (20.106), the City is required to submit quarterlyConstruction Progress and...

Finding 2024-012 Significant Deficiency and Noncompliance Finding, Reporting – Special Reporting Condition: For the Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs (20.106), the City is required to submit quarterlyConstruction Progress and Inspection Reports which cover one calendar quarter and must be submitted to their regional Federal Aviation Administration (FAA) Office by the last day of the month following the end of the period covered. The City is also required to submit various annual reports which are due by December 31(construction projects) or October 30 (nonconstruction projects). There were 14 Reports required to be submitted during the audit period. A sample of five reports were selected for testing. One of the five reports tested was submitted 1 day after the required deadline. The sample was not intended to be, and was not, a statistically valid sample. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized reporting process under a designated grants/finance lead. These reports are prepared by a consultant and reviewed by the City prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

View Audit 399363

Finding 1208386 (2024-018)

Material Weakness 2024

City of Danbury

CT

Reporting

Finding 2024-018: Significant Deficiency in Internal Control – Completeness and Accuracy of the SEFA Condition: For the Education Stabilization Fund- Elementary and Secondary School Emergency Relief (84.425D), American Rescue Plan Elementary and Secondary School Emergency Relief (84.425U) (collectiv...

Finding 2024-018: Significant Deficiency in Internal Control – Completeness and Accuracy of the SEFA Condition: For the Education Stabilization Fund- Elementary and Secondary School Emergency Relief (84.425D), American Rescue Plan Elementary and Secondary School Emergency Relief (84.425U) (collectively ESSERS) and Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218) resulted in 2023 expenditures reported in our 2024 fiscal year expenditures. Per the Committee of Sponsoring Organizations (COSO) Framework – control activities: Proper review of the schedule of expenditures of federal awards (SEFA) and schedule of expenditure of state awards (SESA) should ensure the accuracy and completeness of the schedules. Contact Person: Joanne Sterk, Assistant Director of Finance – Operations, City of Danbury Contact Person: Michael Weaver, CFO, Danbury Public Schools Corrective Actions Completed: We agree with the finding. The City and Danbury Public Schools are monitoring the timing of purchase orders and vendor invoices to encumber for late invoicing.

View Audit 399363

Finding 1208377 (2024-015)

Material Weakness 2024

City of Danbury

CT

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Finding 2024-015 Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Education Stabilization Fund- Elementary and Secondary School Emergency Relief (84.425D), American Rescue Plan Elementary and Secondary School Emergency Relief (84.425U), the City provide...

Finding 2024-015 Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Education Stabilization Fund- Elementary and Secondary School Emergency Relief (84.425D), American Rescue Plan Elementary and Secondary School Emergency Relief (84.425U), the City provided supporting documentation that was unable to be agreed to the amounts that were submitted to the State in the annual performance report ESF - ESSER Recipient Data Collection Form OMB PRA Number: OMB No. 1810-0749 for the key line items: Line 3.b1 LEA expenditures by ESSER Subgrant fund, expenditure category, and object code, Line 3.b10 Number of specific positions supported with ESSER Funds, 3. Line 3.c Allocation of ESSER funds to schools and criteria used to allocate funds to schools, and Line 5.a Full Time Equivalent positions. Contact Person: Michael Weaver, CFO, Danbury Public Schools Corrective Actions Planned: We agree with the finding. The District acknowledges that a formal reconciliation process did not exist at the time of submission to verify that data entered into the annual ESF-ESSER Recipient Data Collection Form (OMB No. 1810-0749) was agreed to underlying financial records and supporting documentation prior to submission to the State. The District will proactively strengthen internal controls over federal reporting by implementing a formal reconciliation policy and establishing designated review prior to submission. Completion Date: 6/30/2025

View Audit 399363

Finding 1208337 (2024-011)

Material Weakness 2024

City of Danbury

CT

Subrecipient Monitoring Material Weakness Reporting § 200.1 § 200.328

Finding 2024-011 Material Weakness and Material Noncompliance Finding, Reporting – Special Reporting Condition: For Coronavirus State and Local Fiscal Recovery Funds (ALN# 21.027), none of the quarterly Project and Expenditure Reports were submitted as required, and instead the City elected to submi...

Finding 2024-011 Material Weakness and Material Noncompliance Finding, Reporting – Special Reporting Condition: For Coronavirus State and Local Fiscal Recovery Funds (ALN# 21.027), none of the quarterly Project and Expenditure Reports were submitted as required, and instead the City elected to submit an annual Project and Expenditure Report that was submitted past the deadline for the fourth quarterly report. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized SLFRF quarterly reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

View Audit 399363

Finding 1208323 (2024-014)

Material Weakness 2024

City of Danbury

CT

Subrecipient Monitoring Cash Management HUD Housing Programs

Finding 2024-014: Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218), For the entitlement funding allocated to the City, they were required to submit four quarte...

Finding 2024-014: Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218), For the entitlement funding allocated to the City, they were required to submit four quarterly reports during the year and two annual reports. Of the three entitlement reports selected for testing, each one was submitted after the deadline. For the COVID-19 funding allocated to the City, they were required to submit quarterly reports duringthe year for two separate awards, for a total of eight quarterly reports, and one annual report. None of the required COVID-19 funding reports were submitted during the current year. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

View Audit 399363

Finding 1208309 (2024-007)

Material Weakness 2024

Bertie County

NC

Reporting Cash Management

Name of Contact Person: Yolanda White, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twentythree employee day sheets vs. timesheets resulting in more program time reported on the day ...

Name of Contact Person: Yolanda White, Director of Bertie County Department of Social Services Corrective Action/Management's Response: DSS agrees that there were some discrepancies found in two out of twentythree employee day sheets vs. timesheets resulting in more program time reported on the day sheets than the approved timesheets. Supervisors are responsible for ensuring that time reported on an employee day sheets match the timesheets. Bertie County DSS utilizes an Excel spreadsheet provided by Bertie County Government that is completed by each employee monthly to report time worked. As it is the Supervisor's responsibility to verify and approve the accuracy of employee day sheets, the Supervisor is expected to reconcile time reported on employee day sheets to time reported on employee timesheets. Plan of Action: • Provide employees training on how to complete their Day Sheets • Reiterate the importance of employees reporting the same amount of time on the day sheet vs. the timesheet. • Communicate with Supervisors the importance of reconciling employee day sheets vs. timesheets. Proposed Completion Date: As soon as the discrepancy was identified by the auditor, management began working with staff on the importance of tracking their time and the procedures they need to follow to ensure the compliance with federal and state guidelines for the year ending June 30, 2024 while continuing training staff in FY 2025 to ensure compliance.

View Audit 399334

Finding 1208308 (2024-008)

Material Weakness 2024

Bertie County

NC

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Reporting § 200.303

Name of Contact Person: Willie Mack Carawan, Jr., Finance Director Corrective Action/Management's Response: This finding is primarily the result of turnover/ transition/ reporting access of key personnel. Management is working with staff member to establish contact with reporting agencies and to gai...

Name of Contact Person: Willie Mack Carawan, Jr., Finance Director Corrective Action/Management's Response: This finding is primarily the result of turnover/ transition/ reporting access of key personnel. Management is working with staff member to establish contact with reporting agencies and to gain the necessary access for reporting purposes, as well as reporting requirements. Proposed Completion Date: As soon as the discrepancy was identified by the auditor, management began working with staff to list their points of contact in the likelihood they are not available to meet reporting requirements for the year ending June 30, 2024.

View Audit 399334

Finding 1208288 (2024-003)

Material Weakness 2024

Aurora Homes, Inc.

MD

HUD Housing Programs Reporting

Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic up...

Compliance Calendar - Implement a calendar for all federal reporting deadlines with advance reminders - May 2026 Month-End and Year-End Close - Standardize closing procedures; set internal deadlines ahead of REAC requirement - May 2026 Oversight and Monitoring - CFO review of compliance; periodic updates to CEO and Board Finance Committee Contingency Procedure - Submit owner-certified report if audited statements not finalized within 90 days - as needed

View Audit 399315

Corrective Action Plans

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