Corrective Action Plans

Finding 1161344 (2023-008)

Material Weakness 2023

PR

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Views of Responsible Officials and Planned Corrective Action The necessary instructions were given to the accounting staff in order to comply with the reporting requirements established by each federal grant that the Municipality currently manages. Responsible Official: Mrs. Irma M. Vargas Aguirre, ...

Views of Responsible Officials and Planned Corrective Action The necessary instructions were given to the accounting staff in order to comply with the reporting requirements established by each federal grant that the Municipality currently manages. Responsible Official: Mrs. Irma M. Vargas Aguirre, Finance and Budget Director Implementation Date: December 31, 2025

View Audit 371240

Finding 1161105 (2023-001)

Material Weakness 2023

The Imagine Institute

WA

Reporting Significant Deficiency

The Imagine Institute will identify all constracts that meet the federal funds threshold and ensure that the required third-party single audit will be completed in a timely manner in preparation for the DCY Fiscal Review.

View Audit 371102

Finding 1160898 (2023-004)

Material Weakness 2023

Mt Enterprise Community Health Clinic

TX

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Reporting Recommendation: The auditor recommends the Organization maintain documentation produced during UDS preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Streamlined processes and succession plan to...

Reporting Recommendation: The auditor recommends the Organization maintain documentation produced during UDS preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Streamlined processes and succession plan to ensure all relevant information for UDS is maintained accurately and accessible for future audits and financial reporting Name(s) of the contact person(s) responsible for corrective action: David Rodrigues. Planned completion date for corrective action plan: December 2025.

View Audit 370964

Finding 1160396 (2023-005)

Material Weakness 2023

California Asian Pacific Chamber of Commerce

CA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.334

Finding Reference Number: 2023-005 Description of Finding: Unable to provide supporting documentation for one expense sample. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges that...

Finding Reference Number: 2023-005 Description of Finding: Unable to provide supporting documentation for one expense sample. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges that this finding is a deficiency in its procedures. The Director of Finance is reviewing the Chamber’s record retention policies and internal controls to ensure that they are in compliance with 2 CFR § 200.334, and will recommend and implement improvements as needed. Staff responsible for federal grants will receive training on documentation and retention requirements. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: September 2025

View Audit 370809

Finding 1160395 (2023-004)

Material Weakness 2023

California Asian Pacific Chamber of Commerce

CA

Allowable Costs / Cost Principles Significant Deficiency § 200.400

Finding Reference Number: 2023-004 Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. C...

Finding Reference Number: 2023-004 Description of Finding: The allocation of payroll costs to programs are done manually instead of done based on entity-wide timesheets. Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Controller and Director of Finance have implemented an ERP system which allows for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation.We also understand these findings are repetitive from the 2021 and 2022 audits; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2023 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. The implemented ERP system includes electronic timesheets for daily charging to specific grants, as well as more visibility into the proper separation of direct, indirect, and unallowable costs per the CFR. Timesheet training has been performed and timesheet completion is required for all employees each day. This began effective January 1, 2025 and provides support for hours worked/billed, as well as documentation of the certification and approvals that all staff time entered is accurate and in compliance with contract requirements and provides proper support for all grant labor costs and indirect costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Susan Wright, Controller, 256-689-7055, swright@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: January 2025

View Audit 370809

Finding 1160351 (2023-001)

Material Weakness 2023

Legal Aid of Northwest Texas

TX

Allowable Costs / Cost Principles Questioned Costs Procurement, Suspension & Debarment

Finding 2023-001 Major Federal Program; 09.744050 – Legal Services Corporation – Basic Field Grant Compliance Requirements: Allowable Cost and Cost Principles Response and Corrective Action: The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regard...

Finding 2023-001 Major Federal Program; 09.744050 – Legal Services Corporation – Basic Field Grant Compliance Requirements: Allowable Cost and Cost Principles Response and Corrective Action: The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regarding the subject of Purchasing and Property Management. LANWT will review its policies and protocols to require prior purchase approval and exigent circumstances approval. Deadlines shall be calendared by the CEO and the accounting department whenever there is an exigent circumstance and approval will need to be requested within the 30-day notice period. The CEO will remain in periodic contact with LSC if any extenuating circumstances exist. The accounting manual will be updated with this protocol. Date of Completion: June 1, 2024 Person Responsible to Ensure Completion: Maria Thomas-Jones, CEO

View Audit 370737 Questioned Costs: $1

Finding 1160310 (2023-001)

Material Weakness 2023

Trailhead Institute

CO

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

Trailhead is establishing a new Compliance Coordinator role to oversee contract compliance processes. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant and contract, that all necessary documents are properly filed, and that ongoing mon...

Trailhead is establishing a new Compliance Coordinator role to oversee contract compliance processes. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant and contract, that all necessary documents are properly filed, and that ongoing monitoring is in place. This role will be responsible for internal monitoring and auditing. This role will ensure that all grant kick-off meeting follow a standard procedure, including a clear understanding of federal requirements. This position will either complete the FFATA themselves or delegate the responsibility to another. This role will have authority for ensuring the procedures are completed. Furthermore, evidence of the completed procedure will be documented and saved in a newly created contracts database. This database is a centralized storage that will be reviewed during internal compliance checks to ensure all required steps have been completed and documented.

View Audit 370698

Finding 1160174 (2023-008)

Material Weakness 2023

Grand Forks Housing Authority

ND

Questioned Costs HUD Housing Programs Significant Deficiency

Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its polies and procedures for ensuring inspections happen timely. Planned Completion Date for CAP Immediately

View Audit 370549

Finding 1160162 (2023-005)

Material Weakness 2023

Grand Forks Housing Authority

ND

HUD Housing Programs Internal Control / Segregation of Duties Questioned Costs

ontact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their finance staff and will review, implement, and document controls to ensure that REAC filing is done on time. Planned Completion Date for CAP Immediately

View Audit 370549

Finding 1160158 (2023-004)

Material Weakness 2023

Grand Forks Housing Authority

ND

Eligibility Internal Control / Segregation of Duties Questioned Costs

Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their tenant specialists and will review, implement, and document controls that will ensure file reviewed are performed in a timely manner. Planned Completion Date for CAP Immediately

View Audit 370549

Finding 1160115 (2023-013)

Material Weakness 2023

Twin Oaks Juvenile Development, Inc.

FL

Matching / Level of Effort / Earmarking Questioned Costs Student Financial Aid § 200.303

Benjie Read CFO and Felecia Read Staff Accountant, will update the policies and procedures for all program reports and the review of each before submission. We will also negotiate with the grantors for appropriate time frams as some of these time frames are impossible for us to meet in an accurate m...

Benjie Read CFO and Felecia Read Staff Accountant, will update the policies and procedures for all program reports and the review of each before submission. We will also negotiate with the grantors for appropriate time frams as some of these time frames are impossible for us to meet in an accurate manner. These policies will be done within 90 days of audit completion.

View Audit 370516

Finding 1159718 (2023-002)

Material Weakness 2023

Prescott School District No. 402-37

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.

View Audit 370309 Questioned Costs: $1

Finding 1159681 (2023-004)

Material Weakness 2023

Adelante Community Development

CO

Questioned Costs Reporting Significant Deficiency

We will get physical signatures on submitted timesheets.

View Audit 370269

Finding 1159562 (2023-007)

Material Weakness 2023

County of Montgomery

PA

Questioned Costs Reporting Significant Deficiency

2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259,...

2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259, 17.277, 17.278, 17.283, 20.205, 21.023, 21.027, 93.558, 93.959, 93.778, 97.036 Federal Award Identification Number and Year: Various Pass-Through Agency: Various Pass-Through Number(s): Various Award Period: 1/1/2023 – 12/31/23 Type of Finding: Other Matters and Significant Deficiency in Internal Control Over Compliance Condition: The County’s single audit and reporting package was delayed for the year ended December 31, 2023, beyond the due date. Recommendation: The County should evaluate its procedures around timely submission of the single audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the recurrence of the finding is in part a result of the timing of when the finding was issued. The 2023 ACFR was issued on February 14, 2025. The Single Audit began after that in late February 2025. At that point the 2023 Single Audit was already past the submission deadline. The County prioritized completion of the 2023 Single Audit and has allocated staff time from the Controller’s department and hired outside temporary professional staffing to complete the audit. Throughout the process, the Grant Accountant and Controller staff have facilitated communication and information between grant-funded departments and CLA resulting in a quick turnaround and completion of the Single Audit. Continued use of Infor’s grant management system and Project codes are increasing efficiency in accurately completing the SEFA and providing documentation as requested for programs being audited. The County began implementing a grant accounting system as part of our implementation of Infor in mid-2021 and are continuing to work with departments to refine their use of the systems. The County is working to compile information required for the 2024 ACFR, and the 2024 SEFA preparation is underway. To expedite this process, the County has engaged additional contract professional staff and is also in the process of hiring an additional full-time employee in the Grant Accounting area. Depending on external auditor availability and other Financial Audits being conducted, the 2024 SEFA will be complete and ready for review by August 2025, with a goal of timely completion of the 2024 Single Audit by the due date of September 30, 2025. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025

View Audit 370214

Finding 1156794 (2023-004)

Material Weakness 2023

Partners Inland Northwest

WA

Equipment & Real Property Management Special Tests & Provisions Material Weakness

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

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

View Audit 369170

Finding 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

Questioned Costs 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

Corrective Action Plans

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