Corrective Action Plans

Finding 1156794 (2023-004)

Material Weakness 2023

WA

Equipment & Real Property Management Special Tests & Provisions Material Weakness

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

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

View Audit 369170

Finding 1156791 (2023-003)

Material Weakness 2023

Partners Inland Northwest

WA

Eligibility Material Weakness Significant Deficiency

2023-003 Commodity Supplemental Food Program (CSFP) Eligibility Corrective action planned: We have implemented a CSFP application system that requires each element of the application to comply with eligibility standards before continuing to the next step. Anticipated completion date: February 2, 202...

2023-003 Commodity Supplemental Food Program (CSFP) Eligibility Corrective action planned: We have implemented a CSFP application system that requires each element of the application to comply with eligibility standards before continuing to the next step. Anticipated completion date: February 2, 2025 Contact person responsible for corrective action: Justin Carlile Justinc@partnersinw.org

View Audit 369170

Finding 1156443 (2023-001)

Material Weakness 2023

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

WA

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

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

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

View Audit 368718

Finding 1156113 (2023-011)

Material Weakness 2023

City of Stamford, Connecticut

CT

Reporting Eligibility Significant Deficiency § 200.512

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

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

View Audit 368535

Finding 1155827 (2023-006)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155826 (2023-005)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving depos...

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving deposit requirement suspended permanently. If management is successful in negotiations with HUD, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155825 (2023-004)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155824 (2023-003)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155440 (2023-002)

Material Weakness 2023

Promedica Health System and Subsidiaries

OH

Procurement, Suspension & Debarment Significant Deficiency § 200.318 § 200.319 § 200.320

Condition: Controls in place were not adequate to ensure the policy included appropriate procurement thresholds and methods. Planned Corrective Action: Management understands the importance of adhering to procurement thresholds and methods. Procurement policies and grant policies will be updated to ...

Condition: Controls in place were not adequate to ensure the policy included appropriate procurement thresholds and methods. Planned Corrective Action: Management understands the importance of adhering to procurement thresholds and methods. Procurement policies and grant policies will be updated to include federal thresholds and methods to reflect federal Uniform Guidance. Contact person responsible for corrective action: Stephanie Cihon and Andy Vollmar Anticipated Completion Date: October 31,2025

View Audit 367737

Finding 1155311 (2023-017)

Material Weakness 2023

The City of Frederick, Maryland

MD

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring

The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payro...

The City has developed a Personnel Activity Report (PAR) that has each federal grant program available as a drop-down menu item. Employees will be required to indicate time spent on grant activities daily. This PAR will be reviewed an approved by the employees' supervisor and then submitted to Payroll for allocation to appropriate grant funds. The PAR will be retained by Payroll as backup.

View Audit 367551

Finding 1155308 (2023-014)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Eligibility Reporting

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

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

View Audit 367551

Finding 1155307 (2023-013)

Material Weakness 2023

The City of Frederick, Maryland

MD

Subrecipient Monitoring Reporting Significant Deficiency

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

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

View Audit 367551

Finding 1155300 (2023-006)

Material Weakness 2023

The City of Frederick, Maryland

MD

Reporting Subrecipient Monitoring Significant Deficiency

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

View Audit 367551

Finding 1155299 (2023-005)

Material Weakness 2023

The City of Frederick, Maryland

MD

Internal Control / Segregation of Duties Special Tests & Provisions Allowable Costs / Cost Principles

Client intakes are now being updated within the fiscal year, ensuring that client information is accurate and timely. Additionally, the Department's new EHR will prompt providers to update proof of income on an annual basis.

View Audit 367551

Finding 1155294 (2023-007)

Material Weakness 2023

West Side Community Health Services INC

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

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

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

View Audit 367533

Finding 1155293 (2023-006)

Material Weakness 2023

West Side Community Health Services INC

MN

Internal Control / Segregation of Duties Significant Deficiency

2023-006 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend the organization have a review process over determinations to ensure accuracy and provide training as needed to mitigate risk of future errors. We also recommend reviewing procedures in place for ret...

2023-006 Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend the organization have a review process over determinations to ensure accuracy and provide training as needed to mitigate risk of future errors. We also recommend reviewing procedures in place for retaining documentation for sliding fee applications to ensure sufficient detail is retained according to policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review sliding fee policies and procedures in place to improve oversight and provide training to the team members conducting the patient intake and reviewing sliding fee applications. Name(s) of the contact person(s) responsible for corrective action: Bobby Royal Planned completion date for corrective action plan: December 2025

View Audit 367533

Finding 1155052 (2023-006)

Material Weakness 2023

County of Columbia, Pennsylvania

PA

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identi...

2024-006 - Reporting - Significant Deficiency/Noncompliance Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required reports for the quarters ended June 30, 2023, September 30, 2023, and December 31, 2023, were due to be filed by the end of the month after the report end date (July 31, 2023, October 31, 2023, and January 31, 2024, respectively). The County filed its report on August 23, 2023, November 17, 2023, and February 15, 2024 (23, 17, and 15 days, respectively), after the required due date. Views of Responsible Officials and Planned Corrective Actions: Management understands and will seek to implement procedures to ensure future reports are submitted timely. Individual Responsible: Finance Department Timeline for corrective action: By December 31, 2024

View Audit 367366

Finding 1153298 (2023-011)

Material Weakness 2023

Community Legal Aid Society, Inc.

DE

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.32

This has been corrected with the new Director of Finance. We are making sure that all reports are filed on time and correctly.

View Audit 366514

Finding 576429 (2023-043)

Significant Deficiency 2023

State of Nevada

NV

Questioned Costs Eligibility Reporting

Finding 2023-043 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Pla...

Finding 2023-043 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan To address the issue of incorrect benefit calculations, DSS has reinforced internal controls requiring supervisory case reviews to verify the accuracy of income information and benefit amounts before case certification. EAP supervisory staff provide ongoing training to case management staff on reviewing documentation and applying program rules accurately. Cases identified with errors are corrected promptly, and trends from supervisory reviews are used to provide targeted staff training. These measures ensure benefit determinations are accurate and consistently applied. Contact Person(s) Responsible Maria Wortman-Meshberger, Social Services Chief III Phone: 775-684-0506 Email: mrwortman@dss.nv.gov Anticipated Completion Date Corrective action in place.

View Audit 366218 Questioned Costs: $1

Finding 576428 (2023-042)

Significant Deficiency 2023

State of Nevada

NV

Cash Management Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Finding 2023-042 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Pla...

Finding 2023-042 Program Information Program Name: Low-Income Home Energy Assistance Covid-19 Low-Income Home Energy Assistance CFDA Number: 93.568 Summary of Finding Significant Deficiency in Internal Control over Compliance Agency Response The agency agrees with this finding. Corrective Action Plan DSS has strengthened internal controls to ensure all reimbursement requests are independently reviewed and approved prior to submission. Each request must now include documented evidence of review and authorization by staff who are not involved in the preparation of the request, ensuring proper segregation of duties. Supporting documentation is validated during the review process, and supervisory sign-off is required to confirm accuracy and compliance. These measures provide assurance that reimbursement requests are fully supported, independently verified, and compliant with program requirements. Contact Person(s) Responsible Brook Barlow, Chief Fiscal Services Phone: 775-684-0659 Email: mrwortman@dss.nv.gov Anticipated Completion Date Corrective Actions have been in place since July 1, 2023.

View Audit 366218

Finding 576384 (2023-025)

Significant Deficiency 2023

State of Nevada

NV

Subrecipient Monitoring Special Tests & Provisions HUD Housing Programs

Audit Finding 2023-025 U.S. Department of Transportation Highway Planning and Construction, 20.205 COVID-19 Highway Planning and Construction, 20.205 Special Tests and Provisions – Value Engineering Significant Deficiency in Internal Control over Compliance Summary of Finding: The Nevada Department ...

Audit Finding 2023-025 U.S. Department of Transportation Highway Planning and Construction, 20.205 COVID-19 Highway Planning and Construction, 20.205 Special Tests and Provisions – Value Engineering Significant Deficiency in Internal Control over Compliance Summary of Finding: The Nevada Department of Transportation (NDOT) is required to establish a value engineering (VE) program and ensure that a VE analysis is performed on all applicable projects. A VE analysis was not performed when required by NDOT policy because NDOT did not have adequate internal controls to ensure their VE policy was followed. Recommendation: NDOT should enhance internal controls to ensure the VE policy is followed or, if necessary, the VE policy is updated as needed and provided that it complies with federal requirements. Agency Response Does the Agency Agree with Finding: Yes Additional Comments: Current NDOT policy has a lower cost threshold (i.e. stricter) for VE analysis than the federal requirement, and the finding references and evaluated project at that lower threshold. NDOT has also had significant organizational and staffing changes since the creation of this, and many other, policies and is currently in the process of updating all agency policies. Corrective Action Action to be Taken: NDOT will update the internal policy and processes relating to VE, including roles and responsibilities and internal controls to match or exceed federal requirements and to meet agency needs and resources. Date of Completion or Estimated Completion: October 1, 2026 Contact Person: Mark Wooster, Performance Analysis Division Head, mwooster@dot.nv.gov

View Audit 366218

Finding 576382 (2023-024)

Significant Deficiency 2023

State of Nevada

NV

Special Tests & Provisions Reporting Significant Deficiency

Finding 2023-024 The minimum standards of BAM case completion were not met. The following is a summary of BAM case completion percentages that were not met: • 90- Day Completion Requirements Paid claims require 95% completion, actual was 85.19%. Denied separation claims require 85% completion, actua...

Finding 2023-024 The minimum standards of BAM case completion were not met. The following is a summary of BAM case completion percentages that were not met: • 90- Day Completion Requirements Paid claims require 95% completion, actual was 85.19%. Denied separation claims require 85% completion, actual was 84.21 %. • 120-Day Completion Requirements Paid claims require 98% completion, actual was 93.46%. Denied separation claims require 98%, actual was 92.76%. Denied non-separation claims require 98%, actual was 93.63%. Recommendation We recommend DETR enhance the internal controls to ensure BAM timeliness requirements are met. Nevada DETR's Response The Employment Security Division's Unemployment Insurance Support Services (UISS) recognizes the importance of BAM timeliness to ensure accuracy of UI benefit payments and compliance with Federal standards. Background: Timeliness issues during the review period were primarily due to workload fluctuations and staffing challenges that affected case completion rates. DETR narrowly missed the timeliness thresholds; however, no systemic issues or deficiencies in investigative procedures were identified. As noted in the U.S. Department of Labor's Annual BAM Administrative Determination Letter for Calendar Year 2023 (April 29, 2024), Nevada's BAM program was found to be in overall compliance, and no response /corrective action was required at the federal level (Attachment A). No new corrective actions were required beyond the continuation of normal BAM operations. Staff performance and workload management returned to standard levels, and DETR achieved full compliance with BAM timeliness requirements in the subsequent review period (202327-202426). DETR will continue to monitor BAM case processing to ensure that timeliness standards are consistently met. Estimated Date of Competion: COMPLETED Contact Person: Patricial Allander, ESD Deputy Administrator, DETR, ESD (775)684-3906, p-allander@detr.nv.gov

View Audit 366218

Finding 576381 (2023-023)

Significant Deficiency 2023

State of Nevada

NV

Reporting Significant Deficiency

Finding 2023-023 Amounts reported on the ETA 9130 report did not agree to underlying financial records. A nonstatistical sample of 11 out of a population of 70 ETA 9130 reports was selected for testing. An error was noted in one of the reports tested as follows: Quarter Ended March 31, 20223 (UI3933...

Finding 2023-023 Amounts reported on the ETA 9130 report did not agree to underlying financial records. A nonstatistical sample of 11 out of a population of 70 ETA 9130 reports was selected for testing. An error was noted in one of the reports tested as follows: Quarter Ended March 31, 20223 (UI39335OB0) Amount Reported Amount Per General Ledger Federal Share of Expenditures $11,551,039 $10,567,580 Recommendation: We recommend the DETR enhance the internal controls to ensure amounts reported agreed to underlying records. Nevada DETR's Response: This was an error due to a prior staff member not interpreting data correctly from the pivot table. DETR has since changed the formatting of pivot tables to be uniform and labeled for more clarity. Attached are the updated procedure and draft internal control for all 9130 reports. Estimated Date of Completion: COMPLETED Contact Person: Zach Hoefling, Chief Financial Officer, DETR/ESD (775)684-3952 z-hoefling@detr.nv.gov

View Audit 366218

Finding 576280 (2023-015)

Significant Deficiency 2023

Dakota County

MN

Significant Deficiency Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.326

U.S. Department of Transportation Highway Planning and Construction Assistance Listing Number: 20.205 Passed Through Minnesota Department of Transportation Pass Through Number: 1918265, 1920180, 1921048, 1921136, 1922210, 1920091, 1920071, 1920134, FLAP043 Award Period: 2023 Recommendation: We re...

U.S. Department of Transportation Highway Planning and Construction Assistance Listing Number: 20.205 Passed Through Minnesota Department of Transportation Pass Through Number: 1918265, 1920180, 1921048, 1921136, 1922210, 1920091, 1920071, 1920134, FLAP043 Award Period: 2023 Recommendation: We recommend the County implement internal controls to verify they are compliant with prevailing wage requirements when a consultant is used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will implement internal control procedures to review certification of payrolls, even when performed by external consultant. Name of the contact person responsible for corrective action: Todd Howard, Assistant County Engineer Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Finding 576279 (2023-014)

Significant Deficiency 2023

Dakota County

MN

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.420 § 200.476

U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Serv...

U.S. Department of Agriculture & U.S. Department of Health and Human Services Supplemental Nutrition Assistance Program Cluster, Temporary Assistance for Needy Families & Medical Assistance Program Assistance Listing Number: 10.561, 93.558, & 93.778 Passed Through Minnesota Department of Human Services Pass Through Number: H55230010, H55214077, & H55215048 Award Period: 2023 Recommendation: We recommend that the County retain documentation of review and approval of all expenditures included in the County’s Cost Allocation Plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will ensure the cost allocation plan is reconciled to the supporting documents and expenditures prior to the final review and signing of the cost allocation plan. Name of the contact person responsible for corrective action: Will Wallo, Finance Director Planned completion date for corrective action plan: December 31, 2024

View Audit 366181

Corrective Action Plans

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