Corrective Action Plans

Finding 312 (2023-002)

Significant Deficiency 2023

Heyworth Community Unit School District No. 4

IL

Equipment & Real Property Management Internal Control / Segregation of Duties Questioned Costs

There is no disagreement with the audit finding. The District’s Grants Manager will collaborate to ensure all program equipment and property purchases exceeding $500 involving federal monies are appropriately tracked.

View Audit 587 Questioned Costs: $1

Finding 246 (2023-002)

Significant Deficiency 2023

Neighborhood Health Center, Inc.

IN

Procurement, Suspension & Debarment Significant Deficiency

Response: The Organization agrees with the finding and will develop a separate procurement policy for use with all federal award expenditures that contains the specific requirements by the Uniform Guidance. Carrie Miles, Chief Executive Officer, will oversee the implementation of this new policy by ...

Response: The Organization agrees with the finding and will develop a separate procurement policy for use with all federal award expenditures that contains the specific requirements by the Uniform Guidance. Carrie Miles, Chief Executive Officer, will oversee the implementation of this new policy by September 30, 2023.

View Audit 489

Finding 119 (2023-002)

Significant Deficiency 2023

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining ...

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 152

Finding 1241219 (2022-002)

Material Weakness 2022

Native Village of Shaktoolik

AK

Reporting Significant Deficiency Internal Control / Segregation of Duties

2022-002 - Reporting - Significant Deficiency in Internal Control over Compliance and Other Matter Name and Contact Person: Desiree Rock, Tribal Administrator Corrective Action Plan: Management will ensure that federal grant reporting is filed timely by the reporting deadlines. Proposed Completion D...

2022-002 - Reporting - Significant Deficiency in Internal Control over Compliance and Other Matter Name and Contact Person: Desiree Rock, Tribal Administrator Corrective Action Plan: Management will ensure that federal grant reporting is filed timely by the reporting deadlines. Proposed Completion Date: December 31, 2026

View Audit 415307

Finding 1240203 (2022-004)

Material Weakness 2022

Ekentucky Advanced Manufacturing Institute INC

KY

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.339 § 200.501 § 200.512 § 200.520

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit an...

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

View Audit 414796

Finding 1240085 (2022-001)

Material Weakness 2022

Public Buildings Authority

PR

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Implement closing calendar, compliance tracking, SEFA standarization and supervisory review.

View Audit 414703

Finding 1239836 (2022-004)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Reporting Allowable Costs / Cost Principles Cash Management

In 2026 CAFF will create a grant bridging document to monitor differences between revenue and expenses and progress against grant budgets. Grant reports in QuickBooks will reflect a full accounting each month for revenue earned and costs incurred (including allocated costs per cost allocation plan).

View Audit 414508

Finding 1239835 (2022-003)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Cash Management Reporting Significant Deficiency

At a minimum CAFF will complete 2023 and 2024 single audits in 2026, and 2025 and 2026 single audits in 2027, bringing us current in 2027. All single audits will be uploaded and certified in the federal clearinghouse database; as part of the Uniform Guidance reporting requirements. Grant Management ...

At a minimum CAFF will complete 2023 and 2024 single audits in 2026, and 2025 and 2026 single audits in 2027, bringing us current in 2027. All single audits will be uploaded and certified in the federal clearinghouse database; as part of the Uniform Guidance reporting requirements. Grant Management staff will be trained on the Uniform Guidance and compliance requirements for federal grants.

View Audit 414508

Finding 1239834 (2022-002)

Material Weakness 2022

Community Alliance with Family Farmers

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Allowable Costs / Cost Principles

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document wi...

In 2026 CAFF will identify all required uniform compliance requirements under each grant and draft written policies and procedures to ensure we remain in compliance, focusing on the 12 basic compliance areas identified in the OMB Compliance Supplement published last year. This compliance document will name the individual accountable and the procedures needed to ensure compliance.

View Audit 414508

Finding 1235934 (2022-002)

Material Weakness 2022

Southeastern Regional Medical Center

NC

Subrecipient Monitoring Cash Management Reporting § 200.512

2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 3...

2022-002 – Reporting – Submission of the Data Collection Form Individuals Responsible for Corrective Action Plan: Sara Bradley, VP/Chief Financial Officer Anticipated Completion Date: September 2026 Management acknowledges that the reporting package and data collection form for the year ended June 30, 2022, was not filed with the Federal Audit Clearinghouse on or before the deadline of March 31, 2023. Management maintains that appropriate schedules and notes thereto were prepared accurately and timely, and that the delay was due primarily to the unique nature of Provider Relief Funds being reported, which resulted in evolving compliance requirements over the funding and reporting periods. Management will file the reporting package and data collection form immediately upon completion and will continue to monitor and adhere to future Federal compliance updates to prevent such delays in the future.

View Audit 411536

Finding 1229757 (2022-005)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Subrecipient Monitoring Cash Management Significant Deficiency § 200.305

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No.10.311 Recommendation: To implement policies, procedures, and trainings to ensure all subrecipient payment requests are reviewed and approved timely...

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Beginning Farmer and Rancher Development Program – Assistance Listing No.10.311 Recommendation: To implement policies, procedures, and trainings to ensure all subrecipient payment requests are reviewed and approved timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a documented review and approval process for subrecipient payment requests. The grant manager will submit each subrecipient payment request to the Executive Director for review prior to payment. The Executive Director's approval will be documented via email, which will be retained along with the corresponding payment request as evidence of review. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026

View Audit 410987

Finding 1229756 (2022-003)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting § 200.303

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Recommendation: To implement a documented review and approval for matching transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding...

Farmers Market and Local Food Promotion Program– Assistance Listing No. 10.175 Recommendation: To implement a documented review and approval for matching transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a quarterly review and approval process for grant matching transactions, performed separately for each grant program. For each program, a spreadsheet summarizing that program's matching transactions received during the prior quarter will be prepared and sent to the Executive Director for review. The Executive Director's approval will be documented via email for each program, retained along with the corresponding supporting spreadsheet as evidence of review. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026

View Audit 410987

Finding 1229753 (2022-004)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.303 § 200.329

Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To implement a procedure that documents the Executive Director's review and approval of the annual REEports, such as retaining evidence of approval through a signed report or email correspondence. In add...

Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To implement a procedure that documents the Executive Director's review and approval of the annual REEports, such as retaining evidence of approval through a signed report or email correspondence. In addition, management should establish controls and provide training to help ensure reports are reviewed, approved, and submitted timely in accordance with applicable requirements Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a documented review and approval process for annual REEports prior to submission. Each year, the completed REEport will be sent to the Executive Director for review, and the Executive Director's approval will be documented via email prior to submission. This email approval will be retained as evidence of review, along with the submitted report. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026

View Audit 410987

Finding 1229752 (2022-002)

Material Weakness 2022

GROW FOOD dba Viva Farms

WA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To provide additional training to employees and supervisors responsible for timesheet preparation and approval to reinforce compliance with established timesheet policies and approval controls. Explanati...

Beginning Farmer and Rancher Development Program – Assistance Listing No. 10.311 Recommendation: To provide additional training to employees and supervisors responsible for timesheet preparation and approval to reinforce compliance with established timesheet policies and approval controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will provide additional training to both employees responsible for preparing timesheets and to supervisors responsible for reviewing and approving them. This training will cover accurate and timely recording of time worked, including proper allocation of time to federal grant programs, and will reinforce Viva Farms' existing timesheet policies and supervisor approval requirements before timesheets are submitted to payroll.. Name(s) of the contact person(s) responsible for corrective action: Rob Smith Planned completion date for corrective action plan: September 30, 2026

View Audit 410987

Finding 1228669 (2022-004)

Material Weakness 2022

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Reporting Significant Deficiency

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures for tracking utility costs and usage in order to accurately complete the HUD- 52722 form. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures for tracking utility costs and usage in order to accurately complete the HUD- 52722 form. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority reviewed its procedures for compiling and reporting utility consumption and cost data used in the preparation of Form HUD-52722. Additional reconciliation procedures have been implemented requiring utility data reported to HUD to be compared to supporting utility tracking records prior to submission. Management has established a secondary review process for utility reporting and provided additional training to staff responsible for preparing and reviewing utility data. These controls are designed to improve the accuracy of utility reporting and ensure compliance with HUD reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Jennifer Palmer, Vice President Finance Planned completion date for corrective action plan: December 31, 2026

View Audit 410330

Finding 1228668 (2022-003)

Material Weakness 2022

Housing Authority of the City of Tulsa

OK

HUD Housing Programs Eligibility Significant Deficiency

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant inc...

Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant income and asset verification to ensure that all required third-party documentation is obtained, retained, and reviewed before certifications are finalized. Supervisory review procedures were enhanced to include verification of income documentation, asset calculations, and tenant file completeness. Staff received refresher training on HUD documentation requirements, income and asset verification procedures, and file quality control standards. In addition, ongoing file audits and management review procedures have been implemented to identify and correct documentation deficiencies promptly. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2026

View Audit 410330

Finding 1228639 (2022-006)

Material Weakness 2022

TOWN OF SPRING LAKE

NC

Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.334

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Caroli...

SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Carolina League of Municipalities to provide additional training to the Town ‘s staff. Proposed Completion Date: December 31, 2026.

View Audit 410277

Finding 1227168 (2022-003)

Material Weakness 2022

County of Rockingham

NH

Reporting Significant Deficiency § 200.303

Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission p...

Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission portal, etc.). These confirmations will be retained in a designated compliance folder for each program. 2. Contingency Plan for System Errors: The County will develop a written contingency plan to address delays caused by system outages or data access issues. This plan will include communication protocols with software vendors, documentation of incidents, and immediate outreach to the granting agency when delays are anticipated. 3. Documenting Extensions and Agency Communication: In any case where a reporting deadline cannot be met, staff will immediately request written approval for extensions from the granting agency, and this correspondence will be retained as part of the official reporting record, as applicable and permitted. 4. Training for Program and Compliance Staff: Staff involved in federal reporting will receive training on reporting deadlines, documentation standards, and escalation protocols for delays. This training will be updated annually to reflect current guidance and program requirements. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 409335

Finding 1227167 (2022-002)

Material Weakness 2022

County of Rockingham

NH

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.303 § 200.334

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 409335

Finding 1227166 (2022-001)

Material Weakness 2022

County of Rockingham

NH

Reporting Significant Deficiency Internal Control / Segregation of Duties

Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required...

Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required to be reported under Federal Assistance Listing Number (ALN) 93.498- COVID-19 - Provider Relief Fund. This resulted in an incomplete reporting of federal expenditures under the appropriate ALN. To address this issue, the County will implement the following corrective actions: 1. Training and Guidance: Staff responsible for SEF A preparation will receive additional training regarding federal reporting requirements, including how to align HRSA filings with SEFA reporting and the appropriate identification of Assistance Listing Numbers. 2. Improved Coordination: The County will establish closer coordination between the departments submitting reports to federal agencies (such as HRSA) and those compiling the SEFA to ensure consistency and completeness. 3. Periodic Reconciliations: The County will implement periodic reconciliations of its general ledger and departmental grant records against federal reporting requirements throughout the fiscal year, rather than waiting until year-end. This will support more timely and accurate SEFA preparation. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 409335

Finding 1227064 (2022-007)

Material Weakness 2022

TOWN OF DOVER, MASSACHUSETTS

MA

Internal Control / Segregation of Duties Reporting Significant Deficiency

Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes i...

Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes in the Town Accountant's office and the new Town Accountant will work to ensure general ledger data is reported accurately as well as review prepared reports thoroughly prior to submission. Planned Implementation Date of Corrective Action: Present Day Person Responsible for Corrective Action: Christopher Costello, Assistant Town Administrator/Finance Director

View Audit 409253

Finding 1225676 (2022-007)

Material Weakness 2022

Quileute Tribal School

WA

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

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to...

Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent NOTE: In addition, Quileute Tribal School has engaged an independent CPA firm to assist with account reconciliations and audit readiness to help ensure that financial information is complete, accurate, and properly reported. Implementation Date: July 30, 2026

View Audit 408537

Finding 1225675 (2022-006)

Material Weakness 2022

Quileute Tribal School

WA

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

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requireme...

Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requirement and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent Implementation Date: July 30, 2026

View Audit 408537

Finding 1224464 (2022-005)

Material Weakness 2022

Monticello Housing Authority

NY

Questioned Costs Procurement, Suspension & Debarment HUD Housing Programs

2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD ...

2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD and Housing Authority policies, in addition to staffing changes, to ensure that this finding will be cleared by the subsequent fiscal year audit. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director

View Audit 407735

Finding 1224463 (2022-004)

Material Weakness 2022

Monticello Housing Authority

NY

HUD Housing Programs Special Tests & Provisions Allowable Costs / Cost Principles

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the proc...

2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the procedures performed to ensure all compliance requirements are met. We recommend a complete review of all Housing Choice Voucher Program tenant file regulations to ensure compliance with these policies. Response: The Executive Director will actively oversee all financial aspects of the agency. Additionally, the director will ensure that finances are current and accurate monthly. A complete review of all Housing Choice Voucher Program tenant file regulations will be performed to ensure compliance with these policies. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director

View Audit 407735

Corrective Action Plans

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