Corrective Action Plans

Finding 303 (2022-001)

Significant Deficiency 2022

GA

Questioned Costs Subrecipient Monitoring Reporting § 200.303

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the F...

Condition We reviewed all subawards made by the grantee during the audit period and found that 4 of them, totaling $224,000, were not reported to the FSRS. Correction action The FSRS will be submitted to the FFATA website. Responsible Person The Chief of Programs and Administration will submit the FSRS under the supervision of the Co-CEO. Anticipated completion date Within 30 days

View Audit 574

Finding 164 (2022-102)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Cash Management Eligibility § 200.303

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director a...

The County is in the final stages of implementing grant policies, which will cover reimbursement procedures for all departmental grants. The County will work with the pass-through grantor to repay the amounts the County received in excess. The County will work with the Health Department director and staff to review grant policies and procedures.

View Audit 240 Questioned Costs: $1

Finding 161 (2022-101)

Material Weakness 2022

Santa Cruz County

AZ

Questioned Costs Matching / Level of Effort / Earmarking § 200.303

To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The Co...

To assist the County, meet the WIOA 75% earmarking requirement for out-of-school youth program, the County will develop written policies and procedures for its WIOA Youth Activities program. The County will provide eligible out-of-school youth the opportunity of paid work experiences (WEX). The County will also work with the pass-through grantor to develop an effective strategy to recruit and retain eligible out-of-school youth. The County will monitor the out-of-school services spending throughout the fiscal year and award period.

View Audit 240 Questioned Costs: $1

Finding 1241641 (2021-014)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Reporting Subrecipient Monitoring § 200.303

Finding No.: 2021-014 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Reporting Questioned Costs: $0 Contact Person(s): Program Manager and Director of DGFI Corrective Action Plan: CHCC agrees with the Findings an...

Finding No.: 2021-014 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Reporting Questioned Costs: $0 Contact Person(s): Program Manager and Director of DGFI Corrective Action Plan: CHCC agrees with the Findings and will establish a stringent records retention policy, even for reports that were electronically completed and submitted using Grantor portals. These fiscal reports were done on the RedCap before 2023 and were readily accessible, hence ELC Program Staff did not maintain separate offline copies of the reports. When ELC transitioned to ELC CAMP, we lost access to the submitted and saved reports. Hence, we cannot provide supporting documents to our assertion that all reports have been submitted. Responsible Official: Program Administrator, Director of DGFI and Chief Financial Officer Proposed Completion Date: On-going

View Audit 415697

Finding 1241640 (2021-013)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.516

Finding No.: 2021-013 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Procurement Suspension and Debarment Questioned Costs: $79,194 Contact Person(s): Program Administrator, Director of DGFI and Chief Financial O...

Finding No.: 2021-013 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Procurement Suspension and Debarment Questioned Costs: $79,194 Contact Person(s): Program Administrator, Director of DGFI and Chief Financial Officer Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $79,194. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that this vendor was not suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $79,194 represents the total expenditure under the seven covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. CHCC Division Grants and Financial Integrity (DGFI), updated our Suspension and Debarment procedure to comply with 2 CFR 180.300. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026

View Audit 415697

Finding 1241639 (2021-012)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.313

Finding No.: 2021-012 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Equipment and Real Property Management Questioned Costs: -0- Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Fin...

Finding No.: 2021-012 AL Program: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Area: Equipment and Real Property Management Questioned Costs: -0- Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241638 (2021-011)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.516

Finding No.: 2021-011 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Procurement Suspension and Debarment Questioned Costs: $352,470 Contact Person(s): Program Manager, Procurement, DGFI Corrective Action Plan: CHCC concurs with the compliance finding con...

Finding No.: 2021-011 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Procurement Suspension and Debarment Questioned Costs: $352,470 Contact Person(s): Program Manager, Procurement, DGFI Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $352,470. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that none of the vendors were suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $352,470 represents the total expenditure under the seven covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. CHCC Division Grants and Financial Integrity (DGFI), updated our Suspension and Debarment procedure to comply with 2 CFR 180.300. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026

View Audit 415697

Finding 1241637 (2021-010)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.313

Finding No.: 2021-010 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Equipment and Real Property Questioned Costs: $-0- Undetermined Contact Person(s): Procurement Director Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital A...

Finding No.: 2021-010 AL Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Area: Equipment and Real Property Questioned Costs: $-0- Undetermined Contact Person(s): Procurement Director Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241636 (2021-009)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding No.: 2021-009 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision – Record of Immunization Questioned Costs: -0- Contact Person(s): Program Administrator, Program Manager Corrective Action Plan: Since 2020, the CHCC has conducted the following steps to ens...

Finding No.: 2021-009 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision – Record of Immunization Questioned Costs: -0- Contact Person(s): Program Administrator, Program Manager Corrective Action Plan: Since 2020, the CHCC has conducted the following steps to ensure that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility. - Ensure that Position Descriptions for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with the VFC Operations Guide, which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Provided training/refresher to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Timeliness and completeness of site visit entries have been incorporated as part of the program’s activity workplan. Site visits were suspended per the CDC Project Officer during that time period due to the COVID-19 response. E-mail communication from the CDC Project Officer is attached. The Program continued to continuously monitor VFC Providers were maintaining proper storage of vaccines and verify that information on vaccination records was maintained by each VFC Provider despite not conducting a formal site visit. Responsible Official: Program Manager, Program Administrator, and Director of Public Health Services Proposed Completion Date: On-going

View Audit 415697

Finding 1241635 (2021-008)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Subrecipient Monitoring Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Finding No.: 2021-008 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision Control, Accountability and Safeguarding of Vaccine Questioned Costs: -0- Contact Person(s): Program Manager Corrective Action Plan: CHCC concurs with the finding. To address this finding, t...

Finding No.: 2021-008 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision Control, Accountability and Safeguarding of Vaccine Questioned Costs: -0- Contact Person(s): Program Manager Corrective Action Plan: CHCC concurs with the finding. To address this finding, the Immunization Program conducts the following reconciliation of vaccination records as follows: Vaccination records: daily entries of vaccination records are captured through the patient encounter form for all providers administering vaccinations. Data Entry Assistants and Program Assistants are responsible for entering the vaccinations based on the form. The Immunization Information Systems (IIS) team are responsible for ensuring data quality elements are complete on the form and reflected on the WebIZ system. Patient screening forms: also known as the patient encounter form is the paper-based document in which patient demographics and vaccination data elements are recorded upon visit for all providers. Data Entry Assistant and Program Assistant capture demographic and input vaccines an individual is to receive for the visit. The vaccinator then inputs vaccination data elements (lot number, manufacturer, site, route, etc.) to be inputted into the registry, WebIZ. Temperature log: utilized to document the vaccine storage unit temperature based on the thermometer reading and logged at the start and end of each workday, as well as after hours and weekends/holidays. The VFC Coordinator and Security team logs the temperatures on a daily, routine basis. Vaccine inventory: monitored weekly by the Logistics Technician via spreadsheet and tracked using the registry WebIZ for overall vaccine inventory management. Inventory is reported to CDC by the Program Manager every 14 days. Vaccine wastage from all providers is submitted to the program at the first week of each month for the previous month reporting period. Overall wastage reporting is done monthly to CDC. A summary report of FY2021 vaccine transactions on the CNMI Immunization Registry, WebIZ was submitted via spreadsheet format under, “Vaccine Inventory Reports” Additionally, the CHCC has conducted the following steps to strengthen that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Provided training to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility. - Ensure that Position Description for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with VFC Operations Guide, which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Entries of vaccine reconciliation documentation such as vaccine inventory (orders, transfers, and wastages) are accessible on the registry, CNMI WebIZ, as well as routine reporting to CDC VtrckS Site visits were suspended per the CDC Project Officer during that time period due to the COVID-19 response. E-mail communication from the CDC Project Officer is attached. The Program continued to continuously monitor VFC Providers were maintaining proper storage of vaccines and reviewing medical records for eligibility screening despite not conducting a formal site visit. Responsible Official: Program Manager, Program Administrator, and Director of Public Health Services Proposed Completion Date: On-going

View Audit 415697

Finding 1241634 (2021-007)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management § 200.303 § 200.313

Finding No.: 2021-007 AL Program: 93.243 Substance Abuse and Mental Health Services Administration Area: Equipment and Real Property Management Questioned Costs: -0- Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findin...

Finding No.: 2021-007 AL Program: 93.243 Substance Abuse and Mental Health Services Administration Area: Equipment and Real Property Management Questioned Costs: -0- Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241633 (2021-006)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Finding No.: 2021-006 AL Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds Area: Activities Allowed or Unallowed Allowable Cost/Cost Principles Questioned Costs: $-0- Contact Person(s): Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC c...

Finding No.: 2021-006 AL Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds Area: Activities Allowed or Unallowed Allowable Cost/Cost Principles Questioned Costs: $-0- Contact Person(s): Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC concurs with the findings. Payroll procedures will be revised to review the calculation of any new differential and review of creation and activation of new pay types to ensure that there is no over or underpayment of benefits. Aside from this preventative control, any supplemental payroll for premium payment shall be reviewed by the Comptroller for compliance to the specific regulations before payment processed. Responsible Official: Comptroller and Payroll Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1241632 (2021-005)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.1 § 200.303 § 200.516

Finding No.: 2021-005 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $304,590 Contact Person(s): Director of Procurement and Supply and Chief Financial Officer, Division of Grants and Financial Integr...

Finding No.: 2021-005 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $304,590 Contact Person(s): Director of Procurement and Supply and Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $304,590. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that neither vendor was suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $304,590 represents the total expenditure under the two covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. This finding is substantially the same as the suspension and debarment findings reported in CHCC’s FY2020 Single Audit. The U.S. Department of the Interior, Office of Insular Affairs, subsequently reviewed CHCC’s corrective-action documentation and determined that CHCC had provided sufficient and appropriate evidence to resolve Finding 2020-005, which included questioned costs of $551,917 Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026

View Audit 415697

Finding 1241631 (2021-004)

Material Weakness 2021

Commonwealth Healthcare Corporation

MP

Equipment & Real Property Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303 § 200.313

Finding No.: 2021-004 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs...

Finding No.: 2021-004 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026

View Audit 415697

Finding 1240076 (2021-001)

Material Weakness 2021

City of Springfield

MA

Reporting Subrecipient Monitoring Material Weakness § 200.303

Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, ma...

Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, management will meet on a quarterly basis to review all Federal Funds and perform reconciliations on a monthly basis. In addition to quarterly financial reviews and monthly financial reconciliations, management will immediately adapt to changing guidelines on Emergencv Federal Funds in future fiscal vears. Planned Implementation Date of Corrective Action: Currently Implemented.

View Audit 414691

Finding 1217594 (2021-001)

Material Weakness 2021

The Arizona Partnership for Immunization

AZ

Questioned Costs Cash Management Eligibility § 200.303

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evid...

Recommendation: The Arizona Partnership for Immunization should formally document its eligibility determination and insurance verification processes to ensure consistent application and compliance with award requirements. In addition, the organization should implement documentation standards to evidence eligibility determinations, particularly during periods of increased service volume, to support accurate and allowable program charges. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action taken in response to finding: Effective 4/2022, management has taken deliberate steps to strengthen documentation and standardize eligibility determination and insurance verification processes. These efforts include the development and formalization of written policies and procedures to ensure consistent application, improved documentation standards, and sustained compliance with HRSA award requirements. Name(s) of the contact person(s) responsible for corrective action: James Washington, Executive Director and Bernie Soderberg, Program Manager. Planned completion date for corrective action plan: December 2023

View Audit 403738

Finding 1216147 (2021-003)

Material Weakness 2021

TOWN OF KNIGHTSTOWN

IN

Procurement, Suspension & Debarment § 200.303

CORRECTIVE ACTION PLAN FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities-Suspension and Debarment Federal Agency: U.S. Department of Agriculture Federal Programs: Water and Waste Disposal Systems for Rural Communities Contact Person Responsible for Corrective A...

CORRECTIVE ACTION PLAN FINDING 2021-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities-Suspension and Debarment Federal Agency: U.S. Department of Agriculture Federal Programs: Water and Waste Disposal Systems for Rural Communities Contact Person Responsible for Corrective Action: Bart Whitesitt-Clerk- Treasurer Contact Phone Number and Email Address: Office: 765-345-5977 Cell: 317-508-7297 Email: bwhitesitt@townofknightstown.in.gov Views of Responsible Officials: We concur with the findings from IN State Board of Accounts entitled: “Internal Control Over Suspension and Debarment Compliance”. We also definitely agree that the Town needs corrective action to prevent using funding from Federal or State grants to pay vendors that have a suspended or debarred status. The Town needs to adopt policies and systems that will strengthen “Material Weakness” and mitigate any “Material Noncompliance”. Description of Corrective Action Plan: Section III Finding: Internal Controls were not followed, concerning the Suspension and Debarment Compliance of the Town utilizing funds from the Rural Communities Grant to pay 3 various vendors who were on the suspended or debarred status list. To prohibit this from happening in the future, I would propose 2 strategies for the Corrective Action Plan. 1. The Town needs to utilize their Engineering Firm, which currently happens to be HWC. In the past, the Engineer has done research on grants and other sources of funding for the Town. The Town should require the Town Engineer to research and keep an updated list of vendors not to use that have a suspended or debarred status. Collecting certification from the vendors the Town use verifying they do not have a suspended or debarred status could also be done by the Town Engineer HWC. 2. The 2nd protocol or policy for the Town to initiate to mitigate using any vendors that have a debarred or suspended status, especially for any projects utilizing any funds from State or Federal Grants, would be for the Town to implement a more advanced approval chain of command process. A more advanced approval chain of command process is already starting to evolve. On or around May 4, 2026, the Town Office is going to “Go Live” and initiate their new Accounting Software program with Boyce Systems. This new program will have a much more advanced and structured approval chain of command processes. The Billing Clerk will initiate the process of approving a batch of APV Vouchers to be approved and checks to be cut to vendors. The Billing Clerk is the first person in the tier of the approval process of bills. With the new software system, the Clerk- Treasurer approves the Deputy-Clerk-Treasurer and the Billing Clerk on the APV checks to the various vendors. Therefore, with the new Boyce Software system the Town is going to there will be 2 more individuals in the approval process that will help mitigate any mistaken invoices or checks to vendors that have a suspended or debarred status. Anticipated Completion Date: 1. The Town has already recently hired a new Engineering Firm HWC. Therefore, I am going to immediately email a request for the Town Engineer HWC to “Red-Flag” the Town not to use any vendors and especially not to pay any vendors with State or Federal Grant funds that have a suspended or debarred status. The Town Engineer HWC will need to keep an updated list that will be ongoing. Collecting certification from the vendor verifying they do not have a suspended or debarred status will ultimately need to be done by the Town Manager, Town Council members, the Town Engineer HWC, the Town Office staff, and the Clerk-Treasurer. Whoever seeks out the vendor will oversee making sure they do not have a suspended or debarred status, very similar to the solicitation of the W-9 of contractors the Town uses. This Corrective Action Plan should take place immediately. 2. The 2nd Corrective Action Plan will take place on or around Approximately May 4, 2026, when the Town Office gets our new Software system. Very simply, having multiple individuals involved in the approval process of Invoices and the distribution of funds to various vendors will greatly behoove the Town’s oversight process. Respectfully Submitted by Clerk-Treasurer Bart Whitesitt INDIANA STATE

View Audit 402611

Finding 1213606 (2021-001)

Material Weakness 2021

Richmond Housing Authority

CA

HUD Housing Programs Internal Control / Segregation of Duties § 200.303

Finding Reference Number: SA2021-001 - Internal Control Assistance Listing Number: 14.850 and 14.872 Assistance Listing Title: Public and Indian Housing and Public Housing Capital Fund Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive D...

Finding Reference Number: SA2021-001 - Internal Control Assistance Listing Number: 14.850 and 14.872 Assistance Listing Title: Public and Indian Housing and Public Housing Capital Fund Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive Director & Rita Martinez, Finance Manager II Corrective Action Plan: The City has assigned staff to specific duties to support the Authority’s financial operations. Staff have implemented new processes that align with the City’s policies and procedures, while also in accordance with HUD regulations and requirements, to improve the integrity and accuracy of the Authority’s financial reporting and management of federal awards. The procedures ensure separation of duties and levels of approval to handle and manage federal funds. Staff also continue to attend trainings to understand Federal statutes and regulations. Completion Date: July 1, 2022

View Audit 400515

Finding 1181992 (2021-009)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Questioned Costs Material Weakness § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of i...

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 393351

Finding 1181990 (2021-008)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Questioned Costs Reporting Significant Deficiency § 200.303

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and subm...

Department of Veterans Affairs Federal Program Name: VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 64.024 Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to ensure that required reports are accurate and submitted within the required timeframe. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented formal reporting controls to ensure all required reports are prepared accurately, reviewed appropriately, and submitted within the required timelines. These controls include a structured reporting calendar with submission deadlines, assignment of responsibility for report preparation and review, and a standardized review and approval process prior to submission. The Organization has also developed documentation procedures to retain evidence of supervisory review, validation of key data points, and confirmation of timely submission. These enhancements are intended to reduce risk of late submissions and improve the accuracy and consistency of program reporting. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 393351

Finding 1169706 (2021-003)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will requ...

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will require approval by the BOCC before any action can be taken. BOCC will determine the validity of each transaction to ensure compliance with grant requirements.

View Audit 382719

Finding 1169705 (2021-002)

Material Weakness 2021

Pittsburg County

OK

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

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in fo...

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1167055 (2021-009)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167054 (2021-008)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167053 (2021-007)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

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