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Corrective Action Plans

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Finding 574452 (2024-002)
Significant Deficiency 2024
Indiana University Health, Inc. and Subsidiaries
IN
Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025
View Audit 364785
Indiana University Health, Inc. and Subsidiaries
IN
Questioned Costs Subrecipient Monitoring Eligibility
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A
View Audit 364785
Finding 574175 (2024-001)
Significant Deficiency 2024
East Texas Crisis Center, Inc.
TX
Internal Control / Segregation of Duties Subrecipient Monitoring Procurement, Suspension & Debarment § 200.112 § 200.303 § 200.331 § 200.333 § 200.338
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allow...
Management agrees with the finding. The Center is currently in the process of updating its fiscal policies and procedures to align with the requirements of 2 CFR Part 200. The Finance Committee is leading this effort and is reviewing each policy area identified, including conflict of interest, allowable costs, subrecipient monitoring, and record retention. Updated policies and procedures will be finalized and presented for Board approval by August 30, 2025. Once approved, the Center will ensure implementation across all departments and provide internal guidance to promote consistent application. Anticipated Completion Date: August 30, 2025 Responsible Party: Finance Committee, with support from Executive Director, Nichole Henry.
View Audit 364753
Medical Debt Resolution, Inc.
NY
Questioned Costs Subrecipient Monitoring Reporting
Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - Dec...
Finding Number: 2024-001 Compliance Requirement: Reporting Programs: United States Department of the Treasury • ALN Number: 21.027 • ALN Name: Coronavirus State and Local Fiscal Recovery Funds • Contract Periods: June 16, 2023 – December 31, 2025 (City of New Orleans, Louisiana); April 1, 2022 - December 31, 2026 (City of Toledo, Ohio); August 1, 2024 - September 30, 2026 (County of Orange, Florida) Management’s Corrective Action Plan: The Organization recognizes the importance of timely reporting to its government partners, and has developed a plan to improve the timeliness of progress reporting, which includes: • Establishing a Government Initiatives department to oversee all government projects, as well as enhance operational efficiency and planning to meet the increased reporting demands from the growing number of grants. • Further expanding internal capacity by hiring additional team members - Vice President of Government Affairs (January 2025), Grant Accountant (June 2025), and Grant Initiatives Program Manager (September 2025), as well as other departments that are integral for programmatic delivery - most importantly, debt acquisition and analysis (Associate Vice President of Analytics) to accelerate and optimize the preparation of data for reporting. • Standardizing the various reporting pertaining to government funders. • Preparing, monitoring, and updating the reporting schedule for government funders. • Utilizing new software to facilitate and track fiscal and progress reporting. • Extending standardized timeframe for progress reporting from 45 days to 60 days on government contracts where available. Person(s) Responsible: Chief Operating Officer (performance reporting) and Vice President, Finance & Administration (fiscal reporting) Expected Completion Date: September 30, 2025
View Audit 364723
Finding 574144 (2024-004)
Significant Deficiency 2024
Christmas Valley Domestic Supply District
OR
Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.328 § 200.329
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
View Audit 364712
Finding 574118 (2024-003)
Material Weakness 2024
Paint Valley Local School District
OH
Subrecipient Monitoring Period of Performance Reporting § 200.328 § 200.344 § 200.502
Management will ensure Federal expenditures are obligated during proper period and reported appropriately.
Management will ensure Federal expenditures are obligated during proper period and reported appropriately.
View Audit 364686
Finding 574104 (2024-001)
Significant Deficiency 2024
Search for Common Ground
DC
Questioned Costs Subrecipient Monitoring Reporting § 200.328
We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took so...
We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available
View Audit 364670
Finding 574102 (2024-002)
Significant Deficiency 2024
Search for Common Ground
DC
Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303
Due to lack of submission date field in Sam.gov system, we agree that we will add an alternate process to document timely submission for subawards reports on Sam.gov. This will be done by downloading the PDF report and confirming through email from Senior compliance officer.
Due to lack of submission date field in Sam.gov system, we agree that we will add an alternate process to document timely submission for subawards reports on Sam.gov. This will be done by downloading the PDF report and confirming through email from Senior compliance officer.
View Audit 364670
Finding 574076 (2024-002)
Material Weakness 2024
City of Palmer, Alaska
AK
Subrecipient Monitoring Material Weakness Reporting
Finding 2024-002 Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will report the subawards to the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System. Future internal controls will...
Finding 2024-002 Reporting – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will report the subawards to the Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting System. Future internal controls will include a review by the Finance Director and the Controller to evaluate the applicability of grant requirements for all grants that the City receives. Anticipated Completion Date Finance plans to have the FFATA report filed by 9/30/2025.
View Audit 364645
Finding 574075 (2024-001)
Material Weakness 2024
City of Palmer, Alaska
AK
Subrecipient Monitoring
Finding 2024-001 Subrecipient Monitoring – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will issue subaward agreements to the organizations that received COSSUP funding during the term of the grant over $30,000. Future inte...
Finding 2024-001 Subrecipient Monitoring – Material Weakness in Internal Control over Compliance and Material Noncompliance Corrective Action Implementation Finance will issue subaward agreements to the organizations that received COSSUP funding during the term of the grant over $30,000. Future internal controls will include a review by the Finance Director and the Controller to evaluate the applicability of grant requirements for all grants that the City receives. Anticipated Completion Date Finance plans to have the subaward agreements issued by 9/30/2025.
View Audit 364645
Finding 574053 (2024-004)
Significant Deficiency 2024
Easter Seals Serving Dc/md/va
MD
Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327
Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automate...
Retrained all staff on procurement policies – the approver misunderstood and thought that because this was a reimbursed cost that the higher level signature was not needed, so we have clarified that approval limits apply regardless of whether it is a reimbursable cost Establishing new, more automated procurement approval process that allows us to set approval levels for each user and will reduce potential for errant approvals Ensure all new management staff receive and acknowledge the procurement policy
View Audit 364634
Finding 574052 (2024-003)
Significant Deficiency 2024
Easter Seals Serving Dc/md/va
MD
Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.510 § 200.518
COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify th...
COO will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly COO will ensure we have written documentation for all federal pass-through funding We have added an experienced grants accountant supervised by the CFO to verify the federal nature of all awards and stay current on SEFA and Uniform Guidance
View Audit 364634
Finding 574045 (2024-001)
Significant Deficiency 2024
United Way of Middle Tennessee, INC
TN
Subrecipient Monitoring § 200.332
2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: ...
2024-001: Internal Control Over Compliance with Subrecipient Monitoring and Noncompliance with Subrecipient Monitoring U.S. Department of Health and Human Services; Passed through the State of Tennessee Department of Health: ALN #93.558 Temporary Assistance for Needy Families Management’s Response: We concur. View of Responsible Officials and Corrective Action: United Way has an Agency Eligibility Review (AER) to ensure an organization is financially sound prior to awarding funding. As part of this process, subrecipients are required to provide their most recent From 990, as well as audited or reviewed financial statements, based on their gross revenue. United Way utilizes the AER as part of subrecipient application process government grants awarded to United Way. Historically, the majority of the government grants awarded to United Way have been for a 12-month period. However, the Temporary Assistance for Needy Families grant represents the first multi-year grant received by United Way from the State. Due to the multi-year nature of this award, United Way initially obtained financial records only after subrecipients entered the program. Going forward, we will review our processes to ensure financial records are collected and reviewed in a timely manner for all multi-year grants. The Senior Director of Innovation & Strategy and the Senior Director of Finance will obtain and review the most recent audited financial statements for the subrecipients. Supporting documentation will be maintained with the grant activity to ensure proper compliance documentation is kept. Name(s) of the Contact Person(s) Responsible for Corrective Action: Rod DeVore and Matt Lim Anticipated Completion Date: September 30, 2025
View Audit 364630
Housing Initiatives, INC
WI
Questioned Costs Subrecipient Monitoring Eligibility
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rent...
2024-002 Department of Housing and Urban Development, Assistance Listing Number 14.239 Home Investment Program: Income Verification Criteria: Organizations that operate rental housing developed with HOME funds are responsible for verifying and documenting tenant income to ensure that units are rented to eligible low-income households. Complete and accurate income documentation is essential to demonstrate compliance with program eligibility requirements and long-term affordability commitments. Condition: During our review of 34 tenant files for HOME-funded rental units, we noted the following: • 6 files did not contain any income verification documentation • 1 file include income documentation, but it was incomplete and missing required supporting documentation Cause: These issues primarily occurred during a transition in property management. The change in personnel and processes led to a lapse in documentation and inconsistent application of income verification procedures. Effect: Without proper income verification, there is a risk that units may be rented to households that do not meet eligibility requirements. Additionally, the absence of documentation may hinder the Organization’s ability to demonstrate compliance during monitoring or audit reviews. Questioned Costs: Not applicable. Auditor’s Recommendation: We recommend that management strengthen internal controls over the income verification process by: • Implementing a standardized checklist for required documentation • Providing staff training on income verification procedures • Conducting supervisory reviews of all files prior to tenant approval, especially during periods of staff transition Auditee’s Response: Management agrees with the finding and has taken steps to address the issue. Four of the seven identified files have been updated with complete income documentation for 2025, and the remaining three are in process. Contact Person: Brad Hinkfuss Anticipated Completion: 9.30.2025
View Audit 364605
Finding 573967 (2024-001)
Significant Deficiency 2024
Old Pueblo Community Services
AZ
Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
The Director of Finance will re-train authorized check signers on the process and importance of reviewing back of the checks being signed by September 2025. A qualified Accountant will be hired by December 2025 to add another level of review in the cash management process.
View Audit 364575
Minnesota Farmers Union
MN
Questioned Costs Subrecipient Monitoring Reporting § 200.512
Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring su...
Recommendation: The auditee implement procedures to ensure the timely submission of future Single Audit reporting packages to the FAC. This may include establishing an internal deadline well in advance of the federal due date, assigning responsibility to a designated staff member, and monitoring submission status. Views of Responsible Officials: Management concurs with the finding and has implemented procedures to ensure future submissions to the FAC are made within the required timeframe.
View Audit 364574
Finding 573883 (2024-006)
Significant Deficiency 2024
Northern Lakes Community Mental Health
MI
Subrecipient Monitoring Cash Management Reporting § 200.303
Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...
Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530
Finding 573882 (2024-005)
Material Weakness 2024
Northern Lakes Community Mental Health
MI
Reporting Subrecipient Monitoring Cash Management § 200.328
Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes...
Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530
Midd-West School District
PA
Subrecipient Monitoring Reporting
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.
View Audit 364515
Finding 573843 (2024-002)
Significant Deficiency 2024
Winnebago County, Wisconsin
WI
Procurement, Suspension & Debarment Subrecipient Monitoring
Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: Ther...
Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County is working on reviewing policies and procedures and updating as necessary. Further, they have hired a Management Analyst to help with training and ensuring grant compliance. Name(s) of the contact person(s) responsible for correction action: Carol Van Gruensven Planned completion date for corrective action: Ongoing
View Audit 364493
Finding 573840 (2024-001)
Significant Deficiency 2024
Central Tribes of the Shawnee Area, Inc.
OK
Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
View Audit 364487
Finding 573826 (2024-014)
Material Weakness 2024
Caddo 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 go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
View Audit 364483
Finding 573825 (2024-013)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
View Audit 364483
Finding 573823 (2024-010)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
View Audit 364483
Finding 573778 (2024-001)
Significant Deficiency 2024
Huntington County
IN
Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: County Commissioners & Auditor Jill Landrum Contact Phone Number and Email Address: 260-358-4805; jill.landrum@huntington.in.us ...
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: County Commissioners & Auditor Jill Landrum Contact Phone Number and Email Address: 260-358-4805; jill.landrum@huntington.in.us Views of Responsible Officials: While the Auditor implemented a procedure for verifying that persons and entities related to contracts or covered transactions were not suspended, debarred, or otherwise excluded, she concurs with Finding 2024-001, in that no internal control procedure was documented that a second person had reviewed the procedure to ensure compliance with the requirements. Description of Corrective Action Plan: The Auditor will work with the Commissioner’s Office Manager Gretchen Lenfestey to discuss changes needed for the previous policy implemented. The new County Attorney has already addressed the need to include Suspension and Debarment language in the contracts that the County signs. If the language is not included, the contractors/vendors will be asked to sign a statement that they have not been suspended, debarred, or otherwise excluded from participating in federal programs. Prior to the Commissioners signing a contract, their Office Manager will be responsible for verifying that each contract contains the Suspension and Debarment language, or that the County has a statement on file from the Contractor/Vendor that they have not been suspended, debarred, or otherwise excluded. The Office Manager will maintain an annual list of all County contracts and will verify with his/her initials that the Suspension and Debarment language is contained in the contract or that there was a separate statement obtained. The Office Manager will send a copy of all signed contracts and signed statements to the Auditor and the Accounts Deputy. On a monthly basis, the Commissioner’s Office Manager will also e-mail an updated list of contracts indicating the documents verified, so the Auditor’s office can verify their records. The Auditor’s Accounts Payable (AP) Deputy will also generate a report from the Financial Software each January to create a list of vendors that were paid more than $25,000 in the previous year. A letter will be mailed requesting the Vendor’s signature on a Suspension and Debarment Certification. They will be asked to return the certification form to the Auditor’s Office by e-mail or mail within 30 days. The AP Deputy will be responsible for keeping a file of the forms received and updating the list with his/her initials. After the 30-day timeframe passes, the Accounts Deputy will double-check the received forms against the mailing list and initial that he/she has verified. The Accounts Deputy, or the Auditor’s designee will conduct a search for exclusions on the Sam.gov website for all vendors that did not return a certification form. A copy of the sam.gov verification will be saved, and the vendor list will be updated & initialed. The Accounts Payable Deputy will double check the verifications to make sure all vendors have either provided a signed certification or that a sam.gov verification was obtained. Anticipated Completion Date: December 31, 2025 Respectfully submitted, Jill M. Landrum Huntington County Auditor INDIANA STATE
View Audit 364450
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