Corrective Action Plans

Finding 1161277 (2024-001)

Material Weakness 2024

NH

Subrecipient Monitoring § 200.332

Update Financial Policies and Procedures to reflect language surrounding areas of deficiency, specifically listed in 2 CFR 200.332(b). New subrecipients awards will include: subrecipient’s unique entity identifier, federal award identification number, federal award date, assistance listing title, as...

Update Financial Policies and Procedures to reflect language surrounding areas of deficiency, specifically listed in 2 CFR 200.332(b). New subrecipients awards will include: subrecipient’s unique entity identifier, federal award identification number, federal award date, assistance listing title, assistance listing number, dollar amount available under each federal award and assistance listing number at the time of disbursement, and approved indirect cost rate. This was found during the 2023 single-audit, with the corrective action implemented for contracts starting after 7/14/25. Planned Implementation Date of Corrective Action: 7/14/25, will be included in Financial Policies revisions in December 2025. Person Responsible for Corrective Action: Director of Finance

View Audit 371198

Finding 1161175 (2024-004)

Material Weakness 2024

Thornton Township High School District 205

IL

Reporting Subrecipient Monitoring

Condition: The District did not comply with the requirements of filing period, quarterly, and final reports by the due dates set by ISBE. A total of 4 reports were filed late. Plan: The Business Office will install stricter controls over grants and grant reporting to ensure these findings are fixed....

Condition: The District did not comply with the requirements of filing period, quarterly, and final reports by the due dates set by ISBE. A total of 4 reports were filed late. Plan: The Business Office will install stricter controls over grants and grant reporting to ensure these findings are fixed. Due to the late completion date of this audit, the results will not be seen until the FY26 audit. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Dr. Albert Holmes

View Audit 371179

Finding 1161166 (2024-005)

Material Weakness 2024

City of Perris

CA

Subrecipient Monitoring Reporting

The City has engaged a consultant to, among other CDBG duties, help with the FFATA reporting compliance. The corrective action will be fully implemented during the Fiscal Year 2025/2026 audit. The contact person for this corrective action is Sabrina Chavez Director of Public Services of the City of ...

The City has engaged a consultant to, among other CDBG duties, help with the FFATA reporting compliance. The corrective action will be fully implemented during the Fiscal Year 2025/2026 audit. The contact person for this corrective action is Sabrina Chavez Director of Public Services of the City of Perris.

View Audit 371177

Finding 1161158 (2024-002)

Material Weakness 2024

Walla Walla County

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

Walla Walla County is taking significant steps to address the recent audit finding regarding inadequate internal controls for compliance with federal requirements. Development of a New Policy To rectify this issue, the county is committed to formulating a new policy specifically tailored to meet fed...

Walla Walla County is taking significant steps to address the recent audit finding regarding inadequate internal controls for compliance with federal requirements. Development of a New Policy To rectify this issue, the county is committed to formulating a new policy specifically tailored to meet federal standards. This development process is already in motion, with the expected completion date set for December 2025. Enhancing Internal Controls We believe that the new policy will significantly improve our internal controls and ensure full compliance with federal mandates. Training Initiatives Additionally, we will seek training opportunities to increase the knowledge of all staff regarding federal programs and compliance requirements, ensuring adherence to these programs and grants.

View Audit 371174

Finding 1161157 (2024-001)

Material Weakness 2024

Walla Walla County

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Walla Walla County employs a decentralized purchasing model. We have implemented training for departments using federally regulated funds to comply with suspension and debarment requirements. Internal controls and processes will be created and/or updated to comply with Federal Suspension and Debarme...

Walla Walla County employs a decentralized purchasing model. We have implemented training for departments using federally regulated funds to comply with suspension and debarment requirements. Internal controls and processes will be created and/or updated to comply with Federal Suspension and Debarment requirements and dispersed to all Departments of the County. The updated procurement policy as mentioned in the corrective action in the Management letter will outline how to handle and follow these requirements. The County will determine which allowable action to be taken in our Internal controls and Procurement policy: 1) check SAM.GOV, 2) make sure the clause is in the contract, 3) sign a suspension and debarment certification. Documentation will be saved and dated to show this requirement was met before the contract has begun.

View Audit 371174

Finding 1161141 (2024-001)

Material Weakness 2024

Grace House INC

MS

Subrecipient Monitoring Cash Management Material Weakness

Views of Responsible Officials and Planned Corrective Action — Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriat...

Views of Responsible Officials and Planned Corrective Action — Grace House has created and will implement the following new controls: a) Every reimbursement request made by any employee will require approval from the Executive Director, Assistant Director, or board of directors vote where appropriate. b) For rental invoices, the immediate supervisor must approve all rental invoices for payment processing before being submitted to the administrative office. If the immediate supervisor is absent, the invoice must be approved by the Executive Director or Assistant Director. c) When a new client invoice is submitted for approval for an existing approved landlord, the invoice along with the traditional client identifying information will be reviewed by both the immediate supervisor and the Executive Director. d) When a new client invoice is submitted for approval for a new landlord, the invoice will be reviewed by both the immediate supervisor and the Executive Director. Each invoice requires a W9 form to validate the legal name, property records verifying ownership matching the legal name on the W9, a picture ID of the individual listed on the W9, and a copy of the agreement if a property management company is listed on the W9 instead of an individual. e) All new clients and landlords will be researched through an investigative software to prove there is no evidence of false identity. f) Grace House has contracted an independent certified fraud investigator to conduct periodic reviews for compliance with fraud prevention policies at least semiannually but beginning quarterly through 2025.

View Audit 371153

Finding 1161076 (2024-002)

Material Weakness 2024

Zanesville-Muskingum County General Health District

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.420 § 200.476

• ZMCHD will continue to educate staff on time and activity reporting. • ZMCHD will create a process to evaluate staff time and effort reporting to ensure the grant is not being overcharged.

View Audit 371068

Finding 1161057 (2024-004)

Material Weakness 2024

Borderlands Restoration Network

AZ

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

● The Organization will develop a policy and procedures that require documentation of subrecipient monitoring for each subrecipient. ● The Organization will redesign the subrecipient contract template to include the federal award identification number and amount of federal funds awarded to each subr...

● The Organization will develop a policy and procedures that require documentation of subrecipient monitoring for each subrecipient. ● The Organization will redesign the subrecipient contract template to include the federal award identification number and amount of federal funds awarded to each subrecipient. ● The Finance Director will distribute the policies and procedures along with the new contract template to all staff that manage grants. ● The Finance Director will train the staff on the new policies and procedures.

View Audit 371025

Finding 1160981 (2024-003)

Material Weakness 2024

Plainview Serenity Center, Inc.

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Procurement, Suspension & Debarment

Corrective Action Plan Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: In response to the finding, management will reinforce its expenditure approval policy by requiring all purchases and payments to have compl...

Corrective Action Plan Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: In response to the finding, management will reinforce its expenditure approval policy by requiring all purchases and payments to have complete documentation and pre-approval from the appropriate level of management. Will perform quarterly internal audits to ensure ongoing compliance. Official Responsible for Ensuring CAP: Paul Walker, Chief Executive Officer Planned Completion Date for CAP: Immediately Plan to Monitor Completion of CAP: The CEO will convene quarterly meetings with the Finance and Compliance departments to review sampled federal transactions for proper documentation and approval. A compliance checklist will be completed and retained for monitoring.

View Audit 371016

Finding 1160904 (2024-005)

Material Weakness 2024

Platte County, Nebraska

NE

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The County has discussed and the County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of expenditures of federal awards and the awards received.

View Audit 370972

Finding 1160886 (2024-007)

Material Weakness 2024

Martin University

IN

Questioned Costs Special Tests & Provisions Student Financial Aid § 200.303

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: During our audit procedures, we noted that the 1 student withdrawal did not have a return to Title IV calculation completed timely as the student officially withdrew 8/29/23 and the calcula...

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.063 Condition: During our audit procedures, we noted that the 1 student withdrawal did not have a return to Title IV calculation completed timely as the student officially withdrew 8/29/23 and the calculation was not completed until 3/24/25. We also noted that the calculation that was performed did not include documentation of the control process to review and approve the calculations prior to changes being made to the student’s award. Auditors’ Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025

View Audit 370945 Questioned Costs: $1

Finding 1160882 (2024-006)

Material Weakness 2024

Martin University

IN

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring § 200.303

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid in...

United States Department of Education Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Condition: Under an institution’s Program Participation Agreement with the Department of Education and the Gramm-Leach-Bliley Act, schools must protect student financial aid information, with particular attention to information provided to institutions by the Department or otherwise obtained in support of the administration of the federal student financial aid programs. Auditors’ Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented a new SIS and Financial Aid processing system. The new systems are Jenzebar products and are fully compliant. Name(s) of the contact person(s) responsible for corrective action: Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2025

View Audit 370945

Finding 1160857 (2024-001)

Material Weakness 2024

Nushagak Electric and Telephone Cooperative, Inc.

AK

Equipment & Real Property Management Subrecipient Monitoring Reporting

Cause: The size and rurality of the Cooperative does not allow for the employment of additional staff to alleviate this condition, as the costs exceed the benefits. Corrective Action Plan: “NETC Management continues to evaluate costs of internally employing resources in comparison with related benef...

Cause: The size and rurality of the Cooperative does not allow for the employment of additional staff to alleviate this condition, as the costs exceed the benefits. Corrective Action Plan: “NETC Management continues to evaluate costs of internally employing resources in comparison with related benefits. Additional efforts shall be placed on implementing additional training and internal controls, as well as working with third party auditors to ensure GAAP compliance.”

View Audit 370943

Finding 1160825 (2024-006)

Material Weakness 2024

School Administrative Unit No. 16

NH

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

The joint baord will adopt policy DAF

View Audit 370927

Finding 1160655 (2024-001)

Material Weakness 2024

Total Community Action, Inc.

LA

Subrecipient Monitoring § 200.332

TCA acknowledges that during the fiscal year 2024, that the agency did not conduct onsite fiscal monitoring of the delegate agencies, due to several personnel and medical challenges and absences within the accounting and fiscal unit. In accordance with policy and procedures stated in the TCA Account...

TCA acknowledges that during the fiscal year 2024, that the agency did not conduct onsite fiscal monitoring of the delegate agencies, due to several personnel and medical challenges and absences within the accounting and fiscal unit. In accordance with policy and procedures stated in the TCA Accounting and Financial Procedures, the TCA fiscal and programmatic team, under the joint supervision of the Chief Financial Officer and Compliance Officer, have updated the procedures and documents to support our full compliance for fiscal year 2025.

View Audit 370916

Finding 1160610 (2024-001)

Material Weakness 2024

Lgarpa CORP Dba Lgar Health & Rehabilitation

PA

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

Finding 2024-001 Condition During the year under audit, the Organization did not make two scheduled debt service payments when due as a result of insufficient available funds. The payments were subsequently remitted after the due dates; however, the Organization was in noncompliance with the terms o...

Finding 2024-001 Condition During the year under audit, the Organization did not make two scheduled debt service payments when due as a result of insufficient available funds. The payments were subsequently remitted after the due dates; however, the Organization was in noncompliance with the terms of its debt agreements at the time of the missed payments. Corrective Action Plan Corrective Action Planned: As noted in Finding 2024-001, recommendations for management to strengthen its cash flow forecasting and monitoring processes to ensure that adequate funds are reserved and available to make debt service payments when due. Name(s) of Contact Person(s) Responsible for Corrective Action: Joann Bazanos, CEO/CFO Anticipated Completion Date: Management is aware of the requirement to make timely debt service payments and has implemented procedures to ensure funds are available when payments are due. As of the report dated October 3, 2025, the Organization is current on all required debt service payments.

View Audit 370901

Finding 1160512 (2024-001)

Material Weakness 2024

Guam Memorial Hospital Authority

GU

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Completion Date: C...

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Completion Date: Completed. Name of Contact Person: Yukari Hechanova, Chief Financial Officer

View Audit 370873 Questioned Costs: $1

Finding 1160425 (2024-002)

Material Weakness 2024

Riordan School Addition Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees w...

Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

View Audit 370837

Finding 1160424 (2024-001)

Material Weakness 2024

Riordan School Addition Housing Development Fund Company, Inc.

NY

Subrecipient Monitoring Reporting § 200.512

Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees...

Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Bessie Riordan Addition Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.

View Audit 370837

Finding 1160398 (2024-002)

Material Weakness 2024

Department of Public Safety

PR

Subrecipient Monitoring Reporting § 200.510

Validate that future federal allocations received in fund 245 are properly classified as federal funds in the SEFA (Schedule of Expenditures of Federal Awards). To ensure compliance with reporting requirements and fiscal transparency, guidance will be provided to the responsible team regarding the a...

Validate that future federal allocations received in fund 245 are properly classified as federal funds in the SEFA (Schedule of Expenditures of Federal Awards). To ensure compliance with reporting requirements and fiscal transparency, guidance will be provided to the responsible team regarding the appropriate procedures for identifying, documenting, and accurately reflecting each federal received in the SEFA. This measure is intended to strengthen internal controls, ensure the traceability of federal resources, and facilitate compliance with external audits and applicable regulations. IMPLEMENTATION DATE Immediately RESPONSIBLE PERSON Lumary Ojeda Ocasio

View Audit 370818

Finding 1160383 (2024-003)

Material Weakness 2024

Trumbull County

OH

Subrecipient Monitoring Material Weakness Reporting

The County will enhance its internal controls over reporting and review federal guidance for reporting under the Coronavirus State and Local Fiscal Recovery Funds.

View Audit 370780

Finding 1160363 (2024-001)

Material Weakness 2024

City of Seatac

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

To address the deficiency and prevent recurrence, the City will implement the following corrective actions: • Policy and Procedure Update: The City will update its written grant management policies to explicitly require verification of suspension and debarment status for all contractors and subrecip...

To address the deficiency and prevent recurrence, the City will implement the following corrective actions: • Policy and Procedure Update: The City will update its written grant management policies to explicitly require verification of suspension and debarment status for all contractors and subrecipients expected to receive $25,000 or more in federal funds, regardless of the initial contract amount or funding estimates. And update the grant procedures to explain how to complete this process. • Grant Administrator Review: The City will require the Grant Administrator (or designated grants compliance staff) to review all contracts or agreements involving federal funds prior to execution to ensure: o The SAM.gov exclusion check has been completed and documented o The required suspension and debarment language or contractor certification is included in the agreement or o All applicable federal compliance requirements are met and properly documented. • Documentation Requirements: SAM.gov verification results will be printed or saved as a PDF and maintained in the contract file. The Grant Administrator will verify this documentation during the review process and before federal funds are disbursed. • Use of Contract Routing Process: The City will incorporate federal grant compliance with the contract routing slip, to be reviewed by the Grant Administrator. This routing slip is required for all contracts. • Staff Training: The City will conduct training for all staff involved in procurement, grant administration, and contract management. This training will cover: o Suspension and debarment requirements, o Proper use of SAM.gov for eligibility verification, o Required contract language and documentation standards, o Roles and responsibilities of the Grant Administrator in ensuring compliance. Anticipated date to complete the corrective action: 12/31/2026

View Audit 370746

Finding 1160268 (2024-007)

Material Weakness 2024

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: November 1, 2025 Views of Responsible Officials and Planned Corrective Action: The debarment check was not done with an ...

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: November 1, 2025 Views of Responsible Officials and Planned Corrective Action: The debarment check was not done with an updated contract for 2024. The 2025 contract renewal and debarment check are being finalized now. Purchasing reviews suspension/debarment checks for procurement over $50,000, but since this was a community partner agreement it was done separately from that process. Departments have now been trained this is required for contracts acquired through purchasing as well as partner agreements.

View Audit 370644

Finding 1160265 (2024-004)

Material Weakness 2024

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of ...

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of the 2023 Single Audit and the hiring of the grants position in early 2025, many previous findings and contracts were not yet corrected in 2024. In the event of this finding, there were two vendors which had minimal expenditures in 2024 (under $5,000 which does not require competitive bids but in aggregate they exceeded that amount). The procurement department had not been consulted, and debarment checks were not completed when the work began in 2023, and final payments were issued in 2024. In the Grants Manual and training departments have been instructed that these procedures must be complied with for all grants.

View Audit 370644 Questioned Costs: $1

Finding 1160262 (2024-005)

Material Weakness 2024

Unified Government of Wyandotte County and Kansas City, Kansas

KS

Subrecipient Monitoring Reporting Significant Deficiency

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs o...

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs over $30,000 will be reported in the FSRS system. Departments will enter the subrecipients into this system, and our grant administrator will audit the files to ensure proper documentation is maintained to ensure compliance.

View Audit 370644

Corrective Action Plans

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