Corrective Action Plans

Finding 539631 (2024-001)

Material Weakness 2024

WA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an indep...

S3800-010: Finding Reference Number 2024-001 S3800-030: Statement of Condition: Management designed Control Activities to ensure compliance with the Eligibility requirement with respect to tenant eligibility. Those Control Activities include verification and review of tenant files by an independent contractor prior to finalization of new tenant move-in. However, during our testing, we noted five (5) move-in files out of five (5) move-in files tested where tenants were approved for move-in prior to review and approval by the independent contractor, circumventing the control. S3800-080: Auditor Recommendation: We recommend that the client immediately implement corrective actions to ensure compliance with internal control procedures. Specifically: 1. The compliance specialist should be required to wait for proper approval of tenant eligibility files before processing them. 2. Review and reinforce the approval process through additional training for staff to ensure they understand the critical importance of obtaining necessary approvals before proceeding. 3. Implement stronger oversight and monitoring mechanisms to ensure that files are not processed before approval. S3800-045: Actions Taken or to be Taken: Management has reviewed the policies and procedures with the property manager, who also serves as the compliance specialist. The property manager was instructed that no tenants are to be granted occupancy until the file has been approved by the independent contractor conducting the compliance review.

View Audit 350177

Finding 539630 (2024-003)

Material Weakness 2024

County of San Joaquin

CA

Subrecipient Monitoring § 200.332 § 200.502

The County acknowledges the importance of proper documentation for subrecipient monitoring. To address this finding, the County will implement the following: 1. Enhanced Review Process – County departments responsible for subrecipient agreements will conduct a thorough review of subrecipient monito...

The County acknowledges the importance of proper documentation for subrecipient monitoring. To address this finding, the County will implement the following: 1. Enhanced Review Process – County departments responsible for subrecipient agreements will conduct a thorough review of subrecipient monitoring activities to ensure compliance with federal and regulations. This will include verifying that all required monitoring steps, including risk assessments and are properly conducted and documented. 2. Documentation and Record-Keeping Improvements – County departments will be required to maintain clear and consistent documentation of all subrecipient monitoring activities. This includes risk assessments, financial reports, site visit records (if applicable), and any corrective actions taken.

View Audit 350172

Finding 539622 (2024-001)

None 2024

City of Seaside

CA

Subrecipient Monitoring

The City concurs with the finding. City staff will ensure CDBG Policies and Procedures are updated to outline process and responsibilities about the new sub-award reporting requirements in SAM.GOV instead of FSRS.gov, which has retired as of March 8, 2025. The City’s SAM.GOV administrator assigned C...

The City concurs with the finding. City staff will ensure CDBG Policies and Procedures are updated to outline process and responsibilities about the new sub-award reporting requirements in SAM.GOV instead of FSRS.gov, which has retired as of March 8, 2025. The City’s SAM.GOV administrator assigned CDBG Staff new roles in SAM.GOV so new contracts and awards can be reported, per FFATA requirements.

View Audit 350160

Finding 539564 (2024-001)

Significant Deficiency 2024

Jewish Community Center of Staten Island, Inc.

NY

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions

2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowled...

2024-001 Special Tests and Provisions Name of Contact Person: Adam Miller, Chief Financial Officer Corrective Action: The JCC was unable to meet certain performance-based provisions of the contract, such as number of participants and break out of those participants by age category. The JCC acknowledges and agrees with the finding, and is in the process of developing procedures to ensure compliance with the grant/contract provisions and will start implementing this recommendation during the year ended June 30, 2025. The procedures: • The JCC will designate the responsibility of contract compliance to a specific individual at the JCC. • The JCC will ensure strict compliance with the IS49 Beacon program’s grant/contract provisions.

View Audit 350115

Finding 539551 (2024-005)

Significant Deficiency 2024

City of Alexandria

VA

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties § 200.213 § 200.303 § 200.318

DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.

View Audit 350101

Finding 539550 (2024-004)

Material Weakness 2024

City of Alexandria

VA

Subrecipient Monitoring Material Weakness Reporting § 200.303

DCHS has reviewed its procedures and will ensure that suspension and debarement status is documented prior to contracting with a vendor.

View Audit 350101

Finding 539549 (2024-003)

Material Weakness 2024

City of Alexandria

VA

Subrecipient Monitoring § 200.303 § 200.332

DCHS has reviewed its procedures and will ensure that subrecipient monitoring activities are documented for compliance review.

View Audit 350101

Finding 539539 (2024-002)

Significant Deficiency 2024

City of Cupertino

CA

Subrecipient Monitoring Special Tests & Provisions Internal Control / Segregation of Duties

The City acknowledges the finding regarding the untimely completion of Quality Assurance Program (QAP) checklists (Appendices K, E, and L) for federally funded projects. Although the required Quality Assurance Tests were performed, documentation of the checklists was not completed in real time. To c...

The City acknowledges the finding regarding the untimely completion of Quality Assurance Program (QAP) checklists (Appendices K, E, and L) for federally funded projects. Although the required Quality Assurance Tests were performed, documentation of the checklists was not completed in real time. To correct this, the City has reinforced internal procedures to ensure that these checklists are completed and signed at the appropriate project milestones. Staff have been retrained on QAP requirements, and a tracking system has been implemented to ensure timely completion of all necessary documentation. Responsible Person: Susan Michael, Capital Improvement Programs Manager Expected Implementation Date: March 2025

View Audit 350078

Finding 539538 (2024-001)

Significant Deficiency 2024

City of Cupertino

CA

Procurement, Suspension & Debarment Subrecipient Monitoring

The City acknowledges the finding related to the lack of documentation for verifying vendors against the System for Award Management (SAM) for federally funded purchases. While the City performed the necessary verification steps, documentation was not consistently maintained. To address this, the Ci...

The City acknowledges the finding related to the lack of documentation for verifying vendors against the System for Award Management (SAM) for federally funded purchases. While the City performed the necessary verification steps, documentation was not consistently maintained. To address this, the City has formalized a process requiring departments to perform and document SAM checks for all applicable vendors. New staff involved in procurement have been trained on these procedures, and verification is now included as a required step in the procurement process. Responsible Person: Susan Michael, Capital Improvement Programs Manager Expected Implementation Date: March 2025

View Audit 350078

Finding 539516 (2024-003)

Significant Deficiency 2024

Region III Workforce Investment Board of Kanawha County, Inc.

WV

Questioned Costs Subrecipient Monitoring § 200.303 § 200.332

2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in ...

2024-003 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement its recently adopted policies and procedures and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in compliance with all federal requirements. Action Taken: The Board has formally integrated the new adopted policies and procedures into our operational framework to ensure consistency and adherence to federal guidelines. Specific staff members have been designated to subrecipient monitoring responsibilities, ensuring adequate oversight and compliance. Executive staff will conduct period internal reviews to assess the effectiveness of our monitoring processes and make improvements as needed.

View Audit 350052 Questioned Costs: $1

Finding 539491 (2024-004)

Material Weakness 2024

Frazer School District

MT

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for fut...

FINDING 2024-004: Impact Aid Application Controls (Repeated 2023-004) Response: The District has implemented that the documentation for the Impact Aid application will be kept in the Business Manager office rather than the Superintendent office to ensure that this documentation is maintained for future years.

View Audit 350039

Finding 539487 (2024-001)

Significant Deficiency 2024

Partners for Home, Inc.

GA

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.332

Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include...

Finding 2024-001 Subrecipient Monitoring, Non-Compliance (Significant Deficiency) Finding Summary: The subawards did not include the required federal provisions or list the assistance listing numbers. Corrective Action Plan for Subrecipient Contracts: Revise all subrecipient contracts to include the federal provisions and list the assistance listing numbers. All LIFT 2.0 contracts will end on December 31, 2024. For those renewed contracts the aforementioned information will be included. All other existing contracts are currently being updated to include this information. The procurement policy will be updated to include this control as well as all other requirements per 2 CFR Section 200.303(a). A reviewer’s checklist will be created using this section to ensure that all future contracts are in compliance. Responsible Individual: Santanna Johnson, Director of Accounting and Contracts Anticipated Completion Date: December 2024

View Audit 350028

Finding 539472 (2024-006)

Significant Deficiency 2024

Urshan College

MO

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: Ther...

Special Tests and Provisions Gramm-Leach-Bliley Act– Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT department continues to improve its processes; an annual review of the WISP has been started and will continue. The Financial Aid Office will work with IT to make sure that the WISP is improved to include and provide secure disposal of customer information and make sure the review is documented. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Student Financial Aid Director Planned completion date for corrective action plan: 6/30/2025

View Audit 350009 Questioned Costs: $1

Finding 539422 (2024-001)

Material Weakness 2024

West Central Illinois Area Agency on Aging

IL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

AAA will create a worksheet to show unpaid balances and will create A/P transactions for those to be reported on monthly financials. Completion date March 31 st, 2025 by fiscal dept

View Audit 349990

Finding 539419 (2024-001)

Significant Deficiency 2024

Town of Lisbon

CT

Procurement, Suspension & Debarment Subrecipient Monitoring

FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awa...

FINDING 2024-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: Thomas Sparkman, First Selectman, (860) 376-3400. Projected Completion Date: March 31, 2025.

View Audit 349988

Finding 539417 (2024-001)

None 2024

East Liberty Family Health Care Center INC

PA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard present...

Analysis is provided on a monthly basis by the Chief Financial Officer and the Accounting department. Balance Sheet, Profit & Loss, Cash Flow and A/P Agings are reviewed and provided to the CEO, the BOD Finance Committee and then to all BOD Members. Also provided is an organization dashboard presentation with 12-14 Key Performance Indicators monthly.

View Audit 349971

Finding 539412 (2024-002)

Significant Deficiency 2024

Siena Heights University

MI

Questioned Costs Student Financial Aid Internal Control / Segregation of Duties § 200.303

Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Fina...

Condition: There was a lack of internal controls in place related to the return of Title IV funds. Planned Corrective Action: Director will update academic calendar on COD R2TIV calculator yearly and verify dates and length of breaks are correct. The University will continue to have the Senior Financial Aid Advisor complete R2TIV and the Director will sign off on calculations. Contact person responsible for corrective action: Callie Zake, Senior Director Student Financial Services Anticipated Completion Date: June 30, 2025

View Audit 349964 Questioned Costs: $1

Finding 539407 (2024-003)

Significant Deficiency 2024

University of St. Thomas

MN

Procurement, Suspension & Debarment Subrecipient Monitoring

Recommendation: CLA recommends the University review its existing policies to ensure it is up to date with federal regulations. They also recommend documenting the subrecipient was checked on the SAM.gov website prior to executing the subaward agreement. CLA suggests a secondary review should be per...

Recommendation: CLA recommends the University review its existing policies to ensure it is up to date with federal regulations. They also recommend documenting the subrecipient was checked on the SAM.gov website prior to executing the subaward agreement. CLA suggests a secondary review should be performed prior to payment and that the second review should be documented and retained to support the suspension and debarment requirements were followed and completed before entering into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: St. Thomas updated processes and procedures to verify subrecipient status’ on a twofold bases. First, at initiation via the Office of Sponsored programs. A secondary review is performed by the Purchasing and Payables team. Name(s) of the contact person(s) responsible for corrective action: Michael Warnock, mjwarnock@stthomas.edu and Karen Harthorn, kmharthorn@stthomas.edu Planned completion date for corrective action plan: This change has been implemented in the spring of 2025.

View Audit 349948

Finding 539406 (2024-002)

Significant Deficiency 2024

University of St. Thomas

MN

Reporting Subrecipient Monitoring Significant Deficiency

Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement wit...

Recommendation: CLA recommends the University implements a process place to ensure the required reporting is completed in the timeline allowed by the granting agency and to complete any missed or late reporting as required. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: St. Thomas identified the applicable FFATA reporting requirements and assigned responsibility to the appropriate party. Name(s) of the contact person(s) responsible for corrective action: Sarah Ervin, sarah.ervin@stthomas.edu Planned completion date for corrective action plan: The additional reporting requirement has been added to the accounting department’s list of responsibilities beginning in January 2025.

View Audit 349948

Finding 539385 (2024-004)

Significant Deficiency 2024

City of Norfolk

VA

Subrecipient Monitoring § 200.303 § 200.332

The Ryan White Office will complete a thorough review of contract templates to identify deviations from required subaward information. Appropriate language to address gaps will be drafted and incorporated into future agreements. Additional training on these requirements will be provided to relevant ...

The Ryan White Office will complete a thorough review of contract templates to identify deviations from required subaward information. Appropriate language to address gaps will be drafted and incorporated into future agreements. Additional training on these requirements will be provided to relevant staff. Future agreements will be monitored to ensure compliance.

View Audit 349937

Finding 539383 (2024-001)

Significant Deficiency 2024

City of Santa Monica

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility § 200.302

Management agrees with the finding and recommendations, but also has determined that this finding will not be repeated in future years, as the arrearages program has come to a close.

View Audit 349915

Finding 539372 (2024-003)

Material Weakness 2024

Argos Community Schools

IN

Special Tests & Provisions Subrecipient Monitoring Material Weakness § 200.303

Description of Corrective Action Plan: Argos Community Schools will ensure that going forward any construction we have done, funded with federal dollars will be compliant with Davis-Bacon Act Reporting laws and ensure we receive required documentation, as required by Federal Law.

View Audit 349901

Finding 539259 (2024-711)

Significant Deficiency 2024

State of Wisconsin

WI

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties

Below please find our response and corrective action plan outline in reference to the above. Action: Provisioning and Deprovisioning Process The University is in the process of developing written procedures of provisioning and deprovisioning user access to our student information system, to include ...

Below please find our response and corrective action plan outline in reference to the above. Action: Provisioning and Deprovisioning Process The University is in the process of developing written procedures of provisioning and deprovisioning user access to our student information system, to include specifying those who are authorized to request user access and assigning responsibility to staff to assess access. This process will be an electronic workflow process which will house documentation of provisioning and deprovisioning activities. Anticipated Completion Date: August 2025 Action: Annual Attestation The University will conduct an audit and annual attestation process which will require managers to attest employee access to the system. Furthermore, every employee will be required to bi-annually confirm their understanding and adherence to specific policies, standards, and regulatory compliance. Action: Current Access to the Student Information System The University is assessing users who currently have access to the SIS. We will remove any student and/or employee who no longer requires access to the system. We will review this on an annual basis. Anticipated Completion Date: May 2025. Person responsible for corrective action: Name: Tammy McGuckin Title: Vice Chancellor for Student Affairs and Enrollment Services Email address; mcguckin@uwp.edu Person responsible for corrective action: Name: Sheronda Glass Title: Vice Chancellor for Operations Email address; glasss@uwp.edu

View Audit 349896

Finding 539258 (2024-710)

Significant Deficiency 2024

State of Wisconsin

WI

Student Financial Aid Reporting Subrecipient Monitoring

Planned Corrective Action: The financial aid office will report enrollment of unofficial withdrawals/last date of attendance on NSLDS upon completion of the Return to Title IV calculations and when unofficial withdrawals are reviewed at the end of each term. The Registrar's Office will review NSC G ...

Planned Corrective Action: The financial aid office will report enrollment of unofficial withdrawals/last date of attendance on NSLDS upon completion of the Return to Title IV calculations and when unofficial withdrawals are reviewed at the end of each term. The Registrar's Office will review NSC G (graduated) not applied reports after submitting degree verify files and corrections will be made, if needed, within 30 day period after submission. Anticipated completion date: financial aid has already acted on this beginning Fall 2024. Registrar's office will begin review of "G Not Applied" reportsbeginning Spring 2025. Person responsiblef or correctiveaction: Financial aid MIchelle Lamb, lamb@uwosh.edu, Alison Casady, casadya@uwosh.edu, Julia Bodette, bodettej@uwosh.edu

View Audit 349896

Finding 539257 (2024-709)

Significant Deficiency 2024

State of Wisconsin

WI

Student Financial Aid Reporting Special Tests & Provisions

Planned Corrective Action: As soon as UW-Milwaukee was notified during the LAB review process that enrollment status effective dates were being reported incorrectly, we took action to correct this issue. While a permanent fix to the extract process from PeopleSoft is dependent on Oracle providing a ...

Planned Corrective Action: As soon as UW-Milwaukee was notified during the LAB review process that enrollment status effective dates were being reported incorrectly, we took action to correct this issue. While a permanent fix to the extract process from PeopleSoft is dependent on Oracle providing a reliable solution to the issue or UW-Milwaukee Information Technology rewriting a custom process and therefore outside of the immediate control of the Registrar’s Office, the Registrar’s Office did immediately start using the “mass correction” feature for the 1800 series warnings provided by the NSC. This will result in enrollment status effective dates which fulfil the Department of Education’s requirements. Since utilizing the “mass correction” option increases the amount of time needed to work through NSC error and warning reports, the Registrar’s Office is hopeful that a more permanent reliable solution on the SIS level will be coming in the future. In the meantime, we will continue to utilize the mass correction option to ensure that enrollment status effective dates are only changed if a student’s enrollment status changes, per the Department of Education’s requirements. UW-Milwaukee Registrar’s Office staff reviewed the records of the five individuals that LAB indicated did not have accurate data reported to the NSLDS. We discovered that the data was reported accurately for enrollment status changes, which would result in a change in effective date. However, it appears that the NSLDS roster request schedule differs from UW-Milwaukee’s enrollment reporting schedule to the NSC. UWMilwaukee reports enrollment information to the NSC on the third Tuesday of each month. It looks like the NSLDS does a roster request at the beginning of the third week of each month. We will investigate if it is possible to adjust our NSC submission schedule to move up by one week, so new data should be available for the mid-month NSLDS roster request. Anticipated Completion Date: May 1, 2025 Person responsible for corrective action: Emily Bach, Records Coordinator UW-Milwaukee Registrar’s Office ecbach@uwm.edu

View Audit 349896

Corrective Action Plans

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