Corrective Action Plans

Finding 529233 (2024-001)

Significant Deficiency 2024

TN

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Management will develop additional controls to ensure that bank reconciliations are prepared timely and perform second review as per current internal control policy.

View Audit 347253

Finding 529203 (2024-001)

Significant Deficiency 2024

Community Health of Central Washington

WA

Allowable Costs / Cost Principles Material Weakness Reporting

The current year Schedule of Findings and Questioned Costs reported no matters in Section II – Financial Statement Findings and one matter in Section III – Federal Award Findings and Questioned Costs. Current year audit findings: 2024-001 Reporting of Draws to UDS Finding Description: Significant D...

The current year Schedule of Findings and Questioned Costs reported no matters in Section II – Financial Statement Findings and one matter in Section III – Federal Award Findings and Questioned Costs. Current year audit findings: 2024-001 Reporting of Draws to UDS Finding Description: Significant Deficiency – Internal Control over Compliance; It was identified that the UDS report submitted for reporting year 2023 was prepared using the accrual basis of accounting instead of the required cash basis. Planned corrective actions: Staff Training and Education: provide training to finance and compliance staff on UDS reporting requirements; require annual refresher training on financial reporting compliance. Review and Reconciliation Procedures: implement an internal review process before UDS report submission to ensure compliance with reporting standards; assign an independent reviewer within the finance team to verify that financial data is recorded on the correct basis before final submission. Internal Control Enhancements: implement periodic internal audits to assess compliance with reporting requirements and accounting standards. Corrective action taken: Upon discovery of this issue, CHCW promptly reviewed the reporting methodology and identified the discrepancy. The finance team corrected this issue for the 2024 UDS report, ensuring that all financial data was reported using the correct cash basis of accounting. Internal controls have been strengthened to prevent future occurrences of similar issues. Completion date: The correction for the 2024 UDS report has been completed. Staff training was conducted January 16, 2025. Review procedures and internal control enhancements have been fully implemented. Contact person responsible for corrective action: Tamiko Wilkens, Controller – Responsible for training and oversight. Desiree Ashbrooks, Chief Financial Officer – Responsible for reviewing and ensuring compliance.

View Audit 347194

Finding 529195 (2024-002)

Significant Deficiency 2024

Many Farms Community School, Inc.

AZ

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN U.S. Department of the Interior Many Farms Community School, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of findings and questioned costs are discusse...

CORRECTIVE ACTION PLAN U.S. Department of the Interior Many Farms Community School, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT 2024-001 Internal Control Over Financial Reporting Type of Finding: Material Weakness in Internal Control Over Financial Reporting Condition: According to generally accepted accounting principles (GAAP), School management is responsible for establishing and maintaining internal controls over financial reporting, to include controls over the School’s accounting records and general ledger transactions. These internal control procedures should include ensuring expenditures are recorded within the correct fiscal year and that revenue and expenditure transactions are properly recorded within the General Ledger. Context: During our review of the School’s accounting records, we noted the following:  The School erroneously recorded $215,173 in expenditures on a fiscal year 2023-2024 encumbrance voucher. This was due to an issue in the financial reporting software with the purchase order not rolling to fiscal year 2024-2025.An audit adjustment was recorded to reverse the expenditures.  An audit adjustment was recorded to accrue an E-Rate reimbursement of $112,919 that was received within the encumbrance period.  The School does not currently have access to its investment account; due to turnover the School does not currently have an authorized signer for the account. The June 2024 statement shows a balance of $2,772,353. The School is currently in litigation to get access to the account. Repeat Finding: Repeated and modified. Action planned in response to finding: The School will implement additional procedures to review revenues and expenditures to ensure that they are recorded in the proper accounting period. Additionally, the School will complete the litigation process to regain access to its investment account. Planned completion date for corrective action plan: For the period ending June 30, 2025. Name of the contact person responsible for corrective action: Ernest Sakeva, Business Manager

View Audit 347177

Finding 529177 (2024-002)

Significant Deficiency 2024

Thomas Edison State University and Its Affiliate the New Jersey State

NJ

Student Financial Aid Special Tests & Provisions Reporting

2024-002 Special Tests (Enrollment Reporting) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025...

2024-002 Special Tests (Enrollment Reporting) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and ALN: Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025), P268K253920 (7/1/2024 – 6/30/2025) Contact Person: Catharine A. Punchello, Vice Provost and University Registrar, 609-984-1180, x3135 Corrective Action: National Student Loan Data System (NSLDS) has resolved the issue causing the Error Code 75 (EC75) errors. Our last large batch of 75 errors was received in response to our Student Status Confirmation Report (SSCR) on July 8, 2024. We received one EC75 on September 13, 2024 and two EC75 on November 8, 2024 and none since then. The University continues to monitor NSLDS’ error reports on our SSCRs to ensure we are aware if they return. The University will continue to submit the SSCR responses to the Clearinghouse and ensure we report individual graduations or enrollment if there are error codes that cannot be resolved timely through the Clearinghouse process. Anticipated Completion Date: Completed

View Audit 347163

Finding 529175 (2024-001)

Significant Deficiency 2024

Thomas Edison State University and Its Affiliate the New Jersey State

NJ

Special Tests & Provisions Student Financial Aid Significant Deficiency

2024-001 Special Tests and Provisions (Verification) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and Assistance Listing Numbers (ALN): Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers:...

2024-001 Special Tests and Provisions (Verification) Federal Agency: Student Financial Assistance Cluster - U.S. Department of Education Program Titles and Assistance Listing Numbers (ALN): Federal Pell Grant Program (ALN 84.063) and Federal Direct Student Loans (ALN 84.268) Federal Grant Numbers: E-P063P243920 (7/1/2024 – 6/30/2025), P268K253920 (7/1/2024 – 6/30/2025) Contact Person: James Owens, Director of Financial Aid, (609) 633-9658 x 3400 Corrective Action: The University has enhanced its report for required verification documentation to highlight those selected with V4 or V5 status to ensure all proper documentation is requested and provided by the students as required for the verification status. The review will be done on a monthly basis throughout the fiscal year. Anticipated Completion Date: April 2025

View Audit 347163

Finding 529166 (2024-001)

Significant Deficiency 2024

University of Maine System

ME

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to the National Student Loan Database System (NSLDS) within the appropriate timefram...

Student Financial Assistance Cluster – Assistance Listing No. Various Recommendation: We recommend the University review its reporting procedures to ensure that students’ statuses are accurately and timely reported to the National Student Loan Database System (NSLDS) within the appropriate timeframe as required by regulations. University of Maine at Farmington Condition: During our testing of 40 students, we noted four students at the University of Maine Farmington (UMF) whose campus enrollment effective date did not match their program enrollment effective date. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: After a similar audit finding in 2022, UMF understood that having the error reports from the National Student Clearinghouse (NSC) would correct this problem going forward. It was subsequently discovered that the internal report used in submitting withdrawals to the NSC pulled the Program Enrollment Effective Date from the wrong location, resulting in instances where the reported date did not match the Enrollment Effective Date. UMF is actively working with UMS IT staff to correct this report. In the meantime, these dates have been updated manually on the NSC website for all withdrawn students, including the four identified in this finding. Name(s) of the contact person(s) responsible for corrective action: Lisa Beane, Assistant Registrar for the University of Maine at Farmington. Planned completion date for corrective action plan: April 2025.

View Audit 347150

Finding 529149 (2024-001)

Significant Deficiency 2024

Mobile Medical Care, Inc.

MD

Questioned Costs Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.318 § 200.319 § 200.320

Views of Responsible Officials:  The Organization will update its procurement policy to be in conformance with Federal cost principles for approval at the next Board Meeting on February 24, 2025.  Supporting operating procedures will be reviewed and adjusted accordingly to ensure compliance with t...

Views of Responsible Officials:  The Organization will update its procurement policy to be in conformance with Federal cost principles for approval at the next Board Meeting on February 24, 2025.  Supporting operating procedures will be reviewed and adjusted accordingly to ensure compliance with the policy by February 28, 2025.  The situation resulting in this finding was for the procurement of support services for a new electronic health records system which was successfully implemented using the services purchased at a reasonable cost; however, the procedures followed by previous staff did not fully comply with the Organization's policies and procedures nor the Federal cost principles. The Organization has since implemented additional procedures to ensure documentation for competitive bids and justification for all purchases to comply with Federal requirements enhancing the Organization's internal procedures. The Organization will do a full review of the Federal cost principles and suggested procedures to ensure full compliance and implement new policies and additional procedures, as necessary, by February 28. 2025.

View Audit 347122 Questioned Costs: $1

Finding 529134 (2024-001)

Significant Deficiency 2024

Timothy L. Johnson Academy

IN

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.329

March 13, 2025 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Timothy L Johnson Academy Elementary school has already taken the following actions to address the FY2024 finding of noncompliance with Federal grant awards: 1. We transitioned to a new business services provid...

March 13, 2025 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Timothy L Johnson Academy Elementary school has already taken the following actions to address the FY2024 finding of noncompliance with Federal grant awards: 1. We transitioned to a new business services provider in FY2025, and part of that transition included a complete overhaul of our grants management. 2. As part of this transition, we created procedures that better integrated our grants management processes with our financial accounting processes. This already allows us to better track the differences in our reimbursement-based grants, cash-basis state reporting, and GAAP-based accounting principles. 3. We also now have a more transparent school-level view of all our grants, which adds a level of control while working with an outsourced business and grants service provider. 4. Dawn Starks and Brad Yoder were responsible on the school side for these procedure changes. Brian Anderson and Kim Tarin from the Center for Innovative Education Solutions were responsible for this as the new business and grants services provider.

View Audit 347076

Finding 529128 (2024-002)

Significant Deficiency 2024

Department of Housing of the Commonwealth of Puerto Rico

PR

Reporting Subrecipient Monitoring Significant Deficiency

VIEWS OF RESPONSIBLE OFFICIALS The designated officer of the CDBG-DR/MIT Program to perform this task resigned suddenly. We recruited and trained a new officer, but during the transition process some First-Tier Sub awardee contracts were not reported in the Subaward Reporting System (FSRS) in a time...

VIEWS OF RESPONSIBLE OFFICIALS The designated officer of the CDBG-DR/MIT Program to perform this task resigned suddenly. We recruited and trained a new officer, but during the transition process some First-Tier Sub awardee contracts were not reported in the Subaward Reporting System (FSRS) in a timely manner. To prevent this condition in the future, we have trained more than one officer for this task, and have placed a level of supervision to fully comply with this obligation. IMPLEMENTATION DATE Already implemented RESPONSIBLE PERSON Félix Hernández Cabán Director of Disaster Recovery CDBG-DR Program Finance & Monitoring Division

View Audit 347065

Finding 528949 (2024-004)

Significant Deficiency 2024

Galena City School District

AK

School Nutrition Programs Reporting Cash Management § 200.303

Finding 2024-004 Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan This occurrence was due to a change in management and the error was corrected when it was identified. Since then, all the documentation was submitted within parameters of ...

Finding 2024-004 Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan This occurrence was due to a change in management and the error was corrected when it was identified. Since then, all the documentation was submitted within parameters of the grant. Expected Completion Date 12/21/2023

View Audit 346942

Finding 528943 (2024-007)

Significant Deficiency 2024

City of Southfield, Michigan

MI

HUD Housing Programs Eligibility Significant Deficiency

Condition: The City had insufficient controls in place that resulted in the City releasing HAP payments on behalf of a participant, despite a failed HQS inspection, which was not rectified within the 30-day cure period or the months that followed. Questioned Costs $1,542 Planned Corrective Action:...

Condition: The City had insufficient controls in place that resulted in the City releasing HAP payments on behalf of a participant, despite a failed HQS inspection, which was not rectified within the 30-day cure period or the months that followed. Questioned Costs $1,542 Planned Corrective Action: The City has implemented controls with our inspection vendors to ensure reinspection is completed within the necessary 30 days and communicated to the PHA. If the owner fails to make the necessary corrections within the 30-day cure period, the PHA will withhold housing assistance payments in accordance with 24 CFR Chapter IX, Part 982 until the PHA verifies the corrections have been made. The City has also implemented a process to ensure reinspection documentation, when applicable, is included in the participant file. We expect this finding to be corrected by June 30, 2025. Contact person responsible for corrective action: Austen Michaels, Director of Fiscal Services and Sherry Veal, Executive Director Section 8 Program Anticipated Completion Date: June 30, 2025

View Audit 346929

Finding 528885 (2024-011)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local o...

Guidance email was provided to program supervisors in February 2025, reiterating the requirement that all RESEA Checklists must be completed by staff and supervisors. Yearly file reviews – Bureau of Workforce Partnership and Operations (BWPO) is currently conducting case file reviews of the local offices. Once the review is completed, each area will get a results email with concerns and recommendations. These reviews started in September 2024 and will continue until they are completed. Anticipated completion is November 2025. Quarterly meetings were held for all local areas (2/4/25, 2/5/25 & 2/6/25). Next quarterly meetings will be held in May 2025. These meetings will reiterate the importance of following the RESEA process as detailed in the RESEA desk guide. Anticipated Completion Date: 11/30/2025 Contact Name: Dorraine Rauch, Division Chief

View Audit 346904

Finding 528884 (2024-010)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing...

L&I has taken the following steps to resolve the finding: - The system issue which caused the lack of denials was fixed in December 2024. - Maximum potential overpayment amount was estimated by getting a list of all those union hiring hall members since the launch of the new system and then removing the following from the list: - Those who registered for work. - Those exempt for other reasons. - Those denied benefits for other reasons. - Those with no payments for weeks beyond the 4th week of the claim. - The remaining individuals’ payments for the fifth week of the claim and later were totaled in January 2025: - 3,481 individuals - $22,597,596.92 - These amounts are described as “maximum” because only an individual review of each claim would reveal if the person was truly not properly registered and if weeks of benefits should be overpaid. - The Department is choosing to waive these individuals’ requirement to register based on UC law section 401(b)(6): The department may waive or alter the requirements of this subsection in cases or situations with respect to which the secretary finds that compliance with such requirements would be oppressive or which would be inconsistent with the purposes of this act. Since the individuals would currently be told of requirements they needed to meet in the past and, as a result, given debts to repay, this is oppressive in nature and inconsistent with the purpose behind the registration requirement. Anticipated Completion Date: Completed Contact Names: Stacy Walter, Management Analyst 2, Special Projects, Office of UC Service Centers; Rick Plesnarski, Management Supervisor, Special Projects Unit & Quality Assurance, Office of UC Service Centers

View Audit 346904 Questioned Costs: $1

Finding 528881 (2024-012)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

BWPO acknowledges that these errors were made, and the indicated accounts were updated immediately. The following steps will be taken to prevent this from happening again. 1. Desk Guides and Training Manuals for Central Offices CWDS Access Administrators will be updated to clearly define what ro...

BWPO acknowledges that these errors were made, and the indicated accounts were updated immediately. The following steps will be taken to prevent this from happening again. 1. Desk Guides and Training Manuals for Central Offices CWDS Access Administrators will be updated to clearly define what roles are restricted to state staff. Completed February 2025. 2. The Access Forms will be updated with the AdministratorLO role being in the restricted roles section and marked as only available to state staff. Completed February 2025. 3. During future reviews of restricted roles CWDS Users with these roles will be checked against staffing lists to confirm their employment status and availability for these roles. To be completed at the next Annual Review of Restricted Roles. A supplementary Annual Restricted Role Audit being completed currently for Restricted Roles. Completed March 2025. Anticipated Completion Date: Completed Contact Name: Jeremy Bender, Customer Service Unit Workforce Development Supervisor BWPO acknowledges that these errors occurred. The accounts were immediately deactivated upon discovery that the staff were no longer with the Commonwealth. The following steps will be taken to prevent a re-occurrence of this issue. 1. Three of the accounts in question were originally BWPO staff who moved to ATO, still needing CWDS Access, and then left state employment at a later date. There is currently not a system in place to review ATO staff separations. Going forward, Monthly Account Deactivation reviews will be expanded to BWDA and ATO with those Bureaus having to attest to all separations during the prior month. This should help ensure the Customer Service Unit is notified timely of staff separations in the other Bureaus. To begin March 31, 2025. 2. During periodic review of deactivations, the Customer Service Unit will compare CWOPA accounts against state staffing lists provided by HR, to ensure separated staff have their accounts deactivated timely. This will likely have to be quarterly or semi-annually as it is unfeasible for HR to have to generate full staff complements monthly for the multiple Bureaus whose CWDS Access BWPO’s Customer Service Unit manages. This will catch any issues that step 1 doesn’t resolve. To begin March 31, 2025. Anticipated Completion Date: 03/31/2025 Contact Name: Jeremy Bender, Customer Service Unit Workforce Development Supervisor

View Audit 346904

Finding 528863 (2024-005)

Significant Deficiency 2024

Commonwealth of Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Eligibility

PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitc...

PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitchen reviews have been completed and 8 of these reviews are in-process or pending final review approval. 2. BFA Field Representatives have been advised that Soup Kitchen reviews must be completed once every four years, just like other TEFAP agencies with which we have direct agreements. This requirement is also being added to the Field Representative work manual. Anticipated Completion Date: 06/30/2025 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance

View Audit 346904 Questioned Costs: $1

Finding 528832 (2024-003)

Significant Deficiency 2024

Lukachukai Community School

AZ

Special Tests & Provisions Significant Deficiency

Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 20...

Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 2025 Planned Corrective Action: It is recommended that the School completes all the outstanding background checks. Secondly, the School will ensure that all background checks are fully completed with the appropriate documents for all newly hired and current employees. It is understood that all current and new employees must be reinvestigated every five years and performed in a timely manner (before “the expiration of the preceding investigation”). This is how the school will attempt to attain compliance.

View Audit 346886

Finding 528775 (2024-002)

Significant Deficiency 2024

Stephens College

MO

Student Financial Aid Reporting Significant Deficiency

AUDIT FINDINGS Finding Reference Number: Finding 2024-002 Description of Finding: Statement of Condition: The Financial Aid Office does not consistently report disbursement dates to COD correctly. Two (2) out of six (6) students tested had been incorrectly reported to COD. Statement of Concurrence o...

AUDIT FINDINGS Finding Reference Number: Finding 2024-002 Description of Finding: Statement of Condition: The Financial Aid Office does not consistently report disbursement dates to COD correctly. Two (2) out of six (6) students tested had been incorrectly reported to COD. Statement of Concurrence or Nonconcurrence: According to 34 CFR 668.164(a), Disbursing Funds, an institution makes a disbursement of Title IV, HEA funds on the date that the institution credits a student’s account at the institution or pays a student or parent directly with funds received from the Secretary; or institutional funds used in advance of receiving Title IV, HEA funds. Corrective Action: To ensure timely and accurate processing of financial aid disbursements, the Office of Accounting and the Office of Financial Aid will implement a Disbursement Memorandum outlining specific procedures. The Office of Accounting must upload disbursement files into PowerCampus on the same day they are received from the Office of Financial Aid. If disbursement files cannot be uploaded due to system issues, staff illness, or other delays, the Office of Accounting must immediately notify the Office of Financial Aid. In such cases, the Office of Financial Aid will update disbursement dates in COD as needed. The Office of Financial Aid already has a process in place to identify and correct mismatches between disbursement dates in PowerFAIDS and COD, and this process will continue as part of ongoing reconciliation efforts. The Office of Accounting will maintain awareness of the importance of same-day uploads and exercise diligence in ensuring compliance with this requirement. This corrective action plan will enhance coordination between offices, reduce discrepancies, and improve compliance with federal reporting requirements. Name of Contact Person: Keri Gilbert Associate Vice President of Financial Aid Analytics and Compliance (573) 876-7106 Projected Completion Date: 3/10/2025

View Audit 346833

Finding 528728 (2024-002)

Significant Deficiency 2024

Fort Worth Transportation Authority

TX

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage ra...

Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage rate applied in this drawdown, Trinity Metro will actively reinforce its internal control processes to ensure detailed reviews related to cost reimbursement rates are accurately identified monthly by those who are authorized to process drawdowns. Implementation will take place immediately. Steps that will be taken include: 􀁸 Dual-Approval Process for Reimbursement Requests: Both the Grants Department and Accounting will confirm the accuracy of the reimbursement rate before submission. 􀁸 Grant Agreement Review Process: Both the Grants Department and Accounting will jointly review grant agreements before submitting reimbursement requests to ensure that the correct rate if applied. Date of Completion: This action plan will go into effect immediately. Person Responsible to Ensure Completion: Contact Person: Greg Jordan, Chief Financial Officer Contact Person: Eva Williams, Director of Budget and Grants, Finance

View Audit 346790 Questioned Costs: $1

Finding 528722 (2024-001)

Significant Deficiency 2024

Froedtert Health, Inc. and Affiliates

WI

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

Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be ...

Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be reinforced regarding time and effort reporting (T/E) and Operations (Ops) will be instructed to hold each drawdown until all processes are completed and approved by the Grant Program Manager. Grant Program Manager will also conduct more frequent internal monitoring of completeness of records, and create an e-learning for all team members involved in the grant process regarding the steps that need to be followed. The Froedtert ThedaCare Health (FTCH) compliance team has created a proposal to implement a Grant Management Software solution. The software solution will have mechanisms for facilitating automated and streamlined processes to support time and effort documentation requirements. Specific actions to be taken include: Party Responsible Laurie Moore, Grant Program Manager Corrective Action Reinforce T/E and implement hold practice with each Ops owner expensing salaries Anticipated Completion Date April 1, 2025 Party Responsible Laurie Moore, Grant Program Manager Corrective Action Increase internal monitoring frequency for grants expensing salaries Anticipated Completion Date Beginning April 15, 2025 and ongoing thereafter Party Responsible Laurie Moore, Grant Program Manager Corrective Action Create e-learning Anticipated Completion Date Create Learning: May 1, 2025 Implementation: June 1, 2025 (If not able to do e-learn, will publish PowerPoint)

View Audit 346753

Finding 528719 (2024-001)

Significant Deficiency 2024

Vail Unified School District No. 20

AZ

Special Tests & Provisions Significant Deficiency

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Impact Aid Assistance Listing Number: 84.041 Contact Person: Michelle Quiroz, Director of Finance Anticipated Completion Date: April 1, 2025 Planned Corrective Action: The District will provide training for all relevant personn...

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Impact Aid Assistance Listing Number: 84.041 Contact Person: Michelle Quiroz, Director of Finance Anticipated Completion Date: April 1, 2025 Planned Corrective Action: The District will provide training for all relevant personnel (procurement team members and project managers) on the need for certified payroll compliance and the consequences of non‐compliance; specifically emphasizing the requirements of the Davis‐Bacon Act and how to properly submit certified payroll documentation. The District will also implement a process to review contractors on federal projects, their compliance with certified payroll requirements, and their contracts to ensure the requirement for timely and accurate certified payroll submissions is included.

View Audit 346729

Finding 528712 (2024-001)

Significant Deficiency 2024

City of Glendale, Arizona

AZ

Procurement, Suspension & Debarment Allowable Costs / Cost Principles HUD Housing Programs

COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement wi...

COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We provided training to procurement staff about the suspension and debarment requirements of 2 CFR 200.214. Further, we expanded language in the City’s formal soliciation template regarding suspension and debarment and added a specifc step on our solitication timeline checklist to perform SAM checks. Name(s) of the contact person(s) responsible for corrective action Levi Gibson, Budget and Finance Director Planned completion date for corrective action plan: December 2024

View Audit 346727

Finding 528709 (2024-001)

Significant Deficiency 2024

Bucknell University

PA

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

Department of Education Bucknell University respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 01, 2023 - June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consisten...

Department of Education Bucknell University respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 01, 2023 - June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2024-001 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review procedures around sending correct information to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Bucknell continues to review and refine its existing process of reporting student enrollment data to the NSLDS at both the campus level and program level. Name(s) of the contact person(s) responsible for corrective action: Tim Kracker, University Registrar and Erin Wolfe, Director, Financial Aid Planned completion date for corrective action plan: December 31, 2024 If the Department of Education has questions regarding this plan, please call Elizabeth D. Stewart, Associate Vice President, Treasurer & Controller at 570-577-3108.

View Audit 346714

Finding 528701 (2024-002)

Significant Deficiency 2024

County of Kent, Michigan

MI

Questioned Costs HUD Housing Programs Eligibility

2024-002 – Documentation of Tenant Eligibility Auditor Description of Condition and Effect: For 1 of 40 tenants tested, there was no evidence of income verification included in the tenant file. Because of this condition there was an increased risk that this tenant's Housing Assistance Payment (HAP...

2024-002 – Documentation of Tenant Eligibility Auditor Description of Condition and Effect: For 1 of 40 tenants tested, there was no evidence of income verification included in the tenant file. Because of this condition there was an increased risk that this tenant's Housing Assistance Payment (HAP) could be assessed inaccurately. Auditor Recommendation: The County should implement a policy requiring all tenants have a documented income verification prior to calculating or disbursing HAP. Management Assessment. Management concurs with the audit assessment regarding this matter. Planned Corrective Action. Management has reviewed its existing policy and will ensure income verification documentation is included in the tenant file. Please note this program ended December 31, 2024. No further HAP payments are being processed at this point in time. Responsible Party. Gustavo Perez, Community Action Director Date of Planned Corrective Action. March 2025

View Audit 346706 Questioned Costs: $1

Finding 528693 (2024-001)

Significant Deficiency 2024

County of Kent, Michigan

MI

HUD Housing Programs Significant Deficiency Special Tests & Provisions

2024-001 – Review and Approval of Housing Quality Standards (HQS) Inspections Auditor Description of Condition and Effect: HQS inspection reports reviewed during testing did not bear evidence of independent review and approval. Because of this condition there was an increased risk that inspection ...

2024-001 – Review and Approval of Housing Quality Standards (HQS) Inspections Auditor Description of Condition and Effect: HQS inspection reports reviewed during testing did not bear evidence of independent review and approval. Because of this condition there was an increased risk that inspection reports could be incomplete or contain inaccuracies. Auditor Recommendation: The County should implement a policy requiring all HQS inspection reports to have an independent review and that such review be sufficiently documented. Management Assessment. Management concurs with the audit assessment regarding this matter. Planned Corrective Action. Management has reviewed its existing policy and will ensure HQS inspection reports have independent reviews which are sufficiently documented. Please note this program ended December 31, 2024. Responsible Party. Gustavo Perez, Community Action Director Date of Planned Corrective Action. March 2025

View Audit 346706

Finding 528657 (2024-001)

Significant Deficiency 2024

North Sweetwater Water and Sewer District

WY

Procurement, Suspension & Debarment Significant Deficiency

Planned Response: The North Sweetwater Water and Sewer District (NSWSD) Board will prepare and adopt written policies and procedures by December 2025, to ensure that all Uniform Guidance regulations, relating to SAMS.gov debarment and suspension, are performed in accordance with federla regulations...

Planned Response: The North Sweetwater Water and Sewer District (NSWSD) Board will prepare and adopt written policies and procedures by December 2025, to ensure that all Uniform Guidance regulations, relating to SAMS.gov debarment and suspension, are performed in accordance with federla regulations and reviewed on a regular basis.

View Audit 346666

Corrective Action Plans

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