Corrective Action Plans

Finding 1217226 (2024-003)

Material Weakness 2024

IN

Subrecipient Monitoring HUD Housing Programs Significant Deficiency § 200.303

Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checkl...

Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file which includes verification of the lease amount and calculation prior to lease execution. Staff have completed refresher training on timing requirements and calculation procedures.

View Audit 403362

Finding 1217224 (2024-001)

Material Weakness 2024

Family Promise of Hendricks County Inc.

IN

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

Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist tha...

Management recognizes the importance of maintaining clear, documented evidence of supervisory review of eligibility determinations, income calculations, and supporting documentation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that includes supervisory review steps requiring documented supervisory sign-off in each tenant file prior to finalizing eligibility. A standardized tracker is also being used to ensure completeness of the process.

View Audit 403362

Finding 1217219 (2024-003)

Material Weakness 2024

Centro Para La Reconstruccion Del Habitat, Inc.

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.329

CORRECTIVE ACTION PLAN: Assign Responsibility Designate the GIS Analyst and Lead Coordinator (or Controller, if applicable) as the individuals responsible for coordinating the preparation and submission of all required progress reports. Require the Chief Financial Officer or Executive Director to re...

CORRECTIVE ACTION PLAN: Assign Responsibility Designate the GIS Analyst and Lead Coordinator (or Controller, if applicable) as the individuals responsible for coordinating the preparation and submission of all required progress reports. Require the Chief Financial Officer or Executive Director to review and approve each report prior to submission. Implement a Compliance Calendar Develop a centralized compliance calendar listing all reporting requirements, due dates, responsible personnel, and review deadlines. Establish automated reminders at least 30, 15, and 5 days before each due date. Create a Reporting Checklist Develop a standardized checklist to ensure that all financial and programmatic information is complete, accurate, and supported by appropriate documentation before submission. Improve Interdepartmental Coordination Conduct regular meetings among program, accounting, and compliance personnel to gather required information and monitor progress toward upcoming deadlines Management Review and Approval Require documented evidence of management review and approval before each progress report is submitted. Maintain Submission Documentation Retain copies of submitted reports, supporting schedules, and confirmation of receipt from PRDOH. Staff Training Provide training to relevant personnel on grant reporting requirements and internal procedures to ensure continued compliance

View Audit 403356

Finding 1216958 (2024-005)

Material Weakness 2024

Half Moon Bay

CA

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

Finding #SA2024-005: Performance Audit Deficiencies Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number...

Finding #SA2024-005: Performance Audit Deficiencies Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP0201 • Name(s) of the contact person: Kenneth Stiles, Finance Manager • Corrective Action Plan: The City will strengthen its procedures for the administration and oversight of federal awards to ensure compliance with applicable federal requirements. Staff will review and update existing grant management procedures, implement additional monitoring and documentation controls, and provide training to personnel involved in federal grant administration. The City will also evaluate opportunities to utilize external resources or consultants, as needed, to support compliance efforts and address identified deficiencies. • Anticipated Completion Date: August 2026

View Audit 403247

Finding 1216955 (2024-002)

Material Weakness 2024

Half Moon Bay

CA

Subrecipient Monitoring Reporting

Finding #SA2024-002: Subrecipient Monitoring and Subgrant Reporting on Schedule of Expenditures of Federal Awards Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through E...

Finding #SA2024-002: Subrecipient Monitoring and Subgrant Reporting on Schedule of Expenditures of Federal Awards Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP0201 • Name(s) of the contact person: Kenneth Stiles, Finance Manager • Corrective Action Plan: The City will strengthen its subrecipient monitoring practices to comply with 2 C.F.R. § 200.332. Specifically, the City will: 1. Conduct a suspension and debarment check on SAM.gov prior to awarding subrecipient agreements. 2. Update its standard subrecipient agreement template to include a requirement that subrecipients notify the City of any noncompliance or misuse of federal funds. 3. Require subrecipients to submit quarterly programmatic and financial reports to demonstrate proper use of funds and progress toward performance goals. 4. For subrecipients expending $750,000 or more in federal funds, obtain and review their Single Audit reports annually. If below the threshold, request and retain a written statement confirming the subrecipient is not subject to Single Audit requirements. 5. Maintain all documentation related to subrecipient monitoring for a minimum of five years and use a standardized checklist to track compliance. 6. Ensure subgrants are reported on the Schedule of Expenditures of Federal Awards. • Anticipated Completion Date: July 2026

View Audit 403247

Finding 1216952 (2024-010)

Material Weakness 2024

City of Waverly

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The Village will establish policies and procedures as required by Uniform Guidance to ensure all compliance with proper Procurement, & Suspension & Debarment compliance requirements.

View Audit 403245

Finding 1216767 (2024-004)

Material Weakness 2024

City of Croswell

MI

Reporting Subrecipient Monitoring Material Weakness

The City will establish procedures whereby the Clerk and Manager will prepare the Schedule of Expenditures of Federal Awards (SEFA) at each fiscal year end.

View Audit 403238

Finding 1216765 (2024-002)

Material Weakness 2024

City of Croswell

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.305 § 200.318 § 200.400

The City will review the requirements for written policies and will adopt policies, as needed, or will revise its current policies as needed to comply with Uniform Guidance.

View Audit 403238

Finding 1216689 (2024-001)

Material Weakness 2024

Casa Esperanza, Inc. and Affiliates

MA

Subrecipient Monitoring Reporting

Finding 2024-001: Timeliness of Reporting During a recent compliance review, it was identified that the organization did not have a formalized process to ensure consistent compliance with the reporting requirements under the Federal Funding Accountability and Transparency Act (FFATA). While the orga...

Finding 2024-001: Timeliness of Reporting During a recent compliance review, it was identified that the organization did not have a formalized process to ensure consistent compliance with the reporting requirements under the Federal Funding Accountability and Transparency Act (FFATA). While the organization maintains strong financial management and grant oversight practices, FFATA-specific procedures had not been explicitly incorporated into written policies, subrecipient agreements, or monitoring tools. Name of Contact Person: Emily Stewart, Chief Executive Officer Applicable Requirement FFATA requires prime recipients of federal funding to report certain subaward and executive compensation information to the federal government to promote transparency in the use of federal funds. These requirements are implemented through federal grant regulations including 2 CFR Part 170 and applicable provisions within 45 CFR Part 75. Corrective Actions Plan: To address this issue and strengthen compliance controls, the organization has implemented the following corrective actions: 1. Retroactive Reporting Completion The organization conducted a comprehensive review of all applicable federal awards. All required FFATA subaward reports from FY19 through the present have been entered into SAM.gov to ensure full compliance with federal reporting requirements. 2. Policy Updates Financial policies and procedures are being updated to include specific guidance regarding FFATA reporting requirements and internal responsibilities for ensuring compliance. 3. Contract Amendments Existing subrecipient agreements have been amended to include an attestation that they are compliant with FFATA requirements and 2 CFR 200. Amended contracts were distributed to all applicable subrecipients to ensure compliance with federal reporting obligations. 4. Subrecipient Monitoring Enhancements The organization has updated its subrecipient monitoring checklist to include verification of FFATA-related compliance requirements as part of ongoing oversight activities. 5. Training and Capacity Building Development staff and the Grants Accountant have registered for a training sponsored by the Department of Justice titled “Pass-through Entity’s Oversight Responsibilities for Subrecipients.” They attended the training online on Wednesday, March 25 2026. We are actively seeking additional compliance training to ensure staff fully understand FFATA requirements and any related compliance obligations. This step is intended to supplement existing financial compliance training and confirm that no additional requirements have been overlooked. Ongoing Monitoring The organization will monitor implementation of these corrective actions and incorporate FFATA compliance into routine grant management and subrecipient monitoring processes moving forward. Conclusion These corrective measures are intended to strengthen internal controls, improve transparency, and ensure full compliance with federal grant reporting requirements going forward. Anticipated Completion Date: Immediately

View Audit 403122

Finding 1216683 (2024-005)

Material Weakness 2024

American Thoracic Society, Inc.

NY

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.502 § 200.510

Views of Responsible Officials and Planned Corrective Actions: The Finance Department will ensure an accurate SEFA in conjunction with the response for Finding 2024-002.

View Audit 403116

Finding 1216603 (2024-011)

Material Weakness 2024

Trimble Local School District

OH

Subrecipient Monitoring Material Weakness Reporting § 200.328

Finding Number: 2024-011 Planned Corrective Action: The district will strengthen procedures for preparing and reviewing Final Expenditure Reports to ensure all reported expenditures agree to the underlying accounting records and supporting documentation. The Treasurer will reconcile grant expenditur...

Finding Number: 2024-011 Planned Corrective Action: The district will strengthen procedures for preparing and reviewing Final Expenditure Reports to ensure all reported expenditures agree to the underlying accounting records and supporting documentation. The Treasurer will reconcile grant expenditures to system reports prior to submission and implement additional review procedures to ensure accurate and compliant federal reporting. Anticipated Completion Date: 05/31/2026 Responsible Contact Person: Ashley Miller

View Audit 403068

Finding 1216601 (2024-009)

Material Weakness 2024

Trimble Local School District

OH

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.403

Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor availab...

Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor available grant balances on a regular basis, and maintain supporting documentation for all federal expenditures and reporting to ensure compliance with federal requirements and accurate reporting on the Schedule of Expenditures of Federal Awards. At the time of the creation of this corrective action plan all COVID-19 related grants have been totally expended. The district is required to provide the board, ODEW, and the Financial Planning Commission with monthly monitoring documents. Within these documents is contained a worksheet that requires the treasurer to list each fund balance for all accounts and explain any negative balances and whether a PCR has been created to eliminate negative balances. This policy forces the district to pay close attention to any grant funds that are carrying negative balances. Anticipated Completion Date: 05/31/2026 Responsible Contact Person: Ashley Miller

View Audit 403068

Finding 1216578 (2024-002)

Material Weakness 2024

Townspeople

CA

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned re...

Management has implemented the following corrective actions: 1. Established a monthly reserve funding schedule that identifies required deposits and due dates. 2. Included replacement reserve funding requirements in the annual budgeting process and monthly financial review procedures. 3. Assigned responsibility to the Executive Director and Finance Committee to monitor compliance with reserve funding requirements. 4. Developed a plan to fund any reserve shortfall through future operating surpluses and/or approved funding sources.

View Audit 403057

Finding 1216576 (2024-001)

Material Weakness 2024

Townspeople

CA

Reporting Internal Control / Segregation of Duties Questioned Costs § 200.512

Management has implemented the following corrective actions: 1. Established a formal year-end closing timeline that includes deadlines for completion of the trial balance, account reconciliations, and supporting schedules. 2. Assigned responsibility to the Executive Director to monitor progress towa...

Management has implemented the following corrective actions: 1. Established a formal year-end closing timeline that includes deadlines for completion of the trial balance, account reconciliations, and supporting schedules. 2. Assigned responsibility to the Executive Director to monitor progress toward year-end closing milestones and ensure information is provided to the auditors on a timely basis. 3. Developed a comprehensive audit preparation checklist identifying all schedules, reconciliations, and documentation required by the auditors. 4. Scheduled pre-audit planning meetings with the auditors to establish mutually agreed-upon deadlines and identify potential issues that could delay audit completion 5. Implemented periodic status reviews during the audit process to monitor progress and address outstanding auditor requests promptly.

View Audit 403057

Finding 1216528 (2024-014)

Material Weakness 2024

Pottawatomie County

OK

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.403

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 403025

Finding 1216527 (2024-013)

Material Weakness 2024

Pottawatomie County

OK

Subrecipient Monitoring § 200.1 § 200.303 § 200.329 § 200.344

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 403025

Finding 1216526 (2024-012)

Material Weakness 2024

Pottawatomie County

OK

Subrecipient Monitoring § 200.332

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

View Audit 403025

Finding 1216525 (2024-011)

Material Weakness 2024

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216524 (2024-010)

Material Weakness 2024

Pottawatomie County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.

View Audit 403025

Finding 1216383 (2024-003)

Material Weakness 2024

County of Carbon

PA

Questioned Costs Student Financial Aid Subrecipient Monitoring

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 14.228, Community Development Block Grants, Passed Through Pennsylvania Department of Community and Economic Development, U.S. Department of Housing and Urban Development; 93.558, Pass-Through Granter #'s C000073823, C000075969, C000082698, C000086225, and C000088719, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available, 21.023, Emergency Rental Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available. Prior Year Finding Number: 2023-005 Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2023 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2023 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. Between staffing and priorities, the County hopes to have cleared by the 2025 audit.

View Audit 402918

Finding 1216303 (2024-003)

Material Weakness 2024

Connecticut Children's Medical Center and Subsidiaries

CT

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconcil...

Corrective Action Planned: Management acknowledges the finding related to the lack of formal policies or procedures in place requiring independent review or approval of vaccine inventory reconciliations prior to submission of the Vaccine Order Form during the time of the audit. 1. Inventory Reconciliation Workflow and System Controls The State of Connecticut utilizes CT WiZ, a centralized vaccine ordering and supply management system. To maintain ordering privileges, the program enforces a strict regulatory safeguard: inventory must be fully reconciled every two weeks. Failure to complete this reconciliation triggers an automated, hard stop within CT WiZ, preventing any additional vaccine orders from being placed. To ensure absolute accuracy and data integrity, our practice executes a standardized, threepart reconciliation process that typically leverages a dual-provider verification model: • Part 1: Physical Count (Floor Staff): Clinical nurses on the floor conduct a manual, physical inventory of all vaccine doses, cross-referencing exact lot numbers and expiration dates. • Part 2: Electronic Health Record Alignment (Coordinator): The designated Vaccine Coordinator reviews the physical counts against the electronic Lot Manager log within Epic to identify and resolve any administrative discrepancies. • Part 3: State System Data Entry (Coordinator): The verified quantities are formally submitted into the CT WiZ portal to complete the biweekly cycle and clear the system for subsequent orders. Staffing Redundancy: While a single coordinator may occasionally manage all three steps if cross-covering the floor, the workflow is deliberately structured to divide tasks between floor nurses (physical counts) and site coordinators (via EMR reconciliation and CT WiZ entry). 2. Vaccine Oversight Team Vaccine operations are managed through a centralized leadership structure with site-specific accountability to ensure consistent oversight at clinic locations. Vaccine operations may be managed by a senior nurse practice manager, practice manager, lead nurse or a backup coordinator. This triad ensures continuous coverage, strict adherence to ordering schedules, and immediate troubleshooting for storage or inventory alerts. 3. Storage, Handling, and Annual Training Compliance In alignment with state oversight expectations and the strict guidelines governing CVP asset management, cold-chain integrity and proper handling are heavily protected. To mitigate risk and standardize knowledge across all care teams, the following educational requirements are mandated: • Mandatory Annual Training: All rostered nursing personnel - including core staff, float pool, and per diem nurses - are strictly required to complete annual training modules dedicated to CVP guidelines and CDC Storage and Handling. • Verification of Competency: Training must be completed through the official CDC TRAIN platform, and employees must submit their earned certificates of completion to clinical leadership to be maintained on file for audit readiness. Name(s) of Contact Person(s) Responsible for Corrective Action: Matthew Farr, VP Ambulatory Operations, Cynthia O’Brien, Senior Nurse Manager Practice Operations Anticipated Completion Date: 01/01/2026

View Audit 402778

Finding 1216237 (2024-010)

Material Weakness 2024

Barclay College

KS

Subrecipient Monitoring Material Weakness

2024-010 Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: We will review items not fully implemented. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216230 (2024-008)

Material Weakness 2024

Barclay College

KS

Student Financial Aid Reporting Subrecipient Monitoring

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice Pr...

Common Origination and Disbursement (COD) Reporting and Reconciliations Planned Corrective Action: Procedures will be implemented to monthly reconcile FDL and Pell disbursements to student accounts with disbursements reported to COD. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026

View Audit 402736

Finding 1216017 (2024-001)

Material Weakness 2024

Southeast Chicago Chamber of Commerce

IL

Reporting Internal Control / Segregation of Duties Questioned Costs § 200.507 § 200.512

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion a...

Management will implement enhanced year-end closing and audit coordination procedures, including earlier preparation timelines, improved tracking of audit deliverables and reporting deadlines, and increased coordination with outsourced accounting and audit partners to help ensure timely completion and submission of future Single Audit reporting packages.

View Audit 402560

Finding 1215997 (2024-001)

Material Weakness 2024

City of Lakewood

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requir...

The City will strengthen its process by requiring documented SAM.gov suspension and debarment checks for all applicable federally funded vendors by ensuring our grant requirements document is up to date and accessible to all staff. The City is currently compliant with suspension and debarment requirements and will ensure the grants requirement document is updated and all federal contracts remain compliant going forward.

View Audit 402546

Corrective Action Plans

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