Corrective Action Plans

Finding 1156593 (2024-005)

Material Weakness 2024

Meeker County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sa...

ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 368940

Finding 1156582 (2024-003)

Material Weakness 2024

Knox County

IN

Internal Control / Segregation of Duties Subrecipient Monitoring § 200.1 § 200.303

FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: W...

FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: We concur with the finding. Description of Corrective Action Plan: The annual reporting for fund 8950 – Coronavirus State and Local Fiscal Recovery Funds with the Treasury shall be prepared by the First Deputy, reviewed by an independent accountant to verify and consult that all the information is correct, and the final report will be reviewed and approved by the County Auditor before submission. Anticipated Completion Date: Next annual reporting Due April 30, 2026 for 2025

View Audit 368932

Finding 1156581 (2024-002)

Material Weakness 2024

Knox County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corre...

FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: We concur with the finding. Description of Corrective Action Plan: The County will provide documentation that the vendor/contractor is not suspended or disbarred from participation in federal award programs. The First Deputy will review the website www.sam.gov, a tool to use to look for active exclusions for the contractor/vendor, for any active exclusions, and the County Auditor will review the verification. Anticipated Completion Date: Immediately

View Audit 368932

Finding 1156578 (2024-003)

Material Weakness 2024

City of Logansport

IN

Procurement, Suspension & Debarment § 200.1 § 200.214 § 200.303 § 200.317 § 200.318

FINDING 2024-003 Finding Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk-Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsi...

FINDING 2024-003 Finding Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk-Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31,2025

View Audit 368925

Finding 1156543 (2024-002)

Material Weakness 2024

Samaritas and Subsidiaries

MI

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...

Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025

View Audit 368884 Questioned Costs: $1

Finding 1156532 (2024-002)

Material Weakness 2024

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Questioned Costs Internal Control / Segregation of Duties § 200.303 § 200.334

Management agrees with the recommendation and will implement stronger review processes to ensure proper documentation is in place to support program activities and reports submitted to the grantor. All staff charged with maintaining client documentation will receive updated training on recordkeeping...

Management agrees with the recommendation and will implement stronger review processes to ensure proper documentation is in place to support program activities and reports submitted to the grantor. All staff charged with maintaining client documentation will receive updated training on recordkeeping requirements, supporting documents specifying such requirements, and supports throughout the year to ensure documents are properly maintained and verified. Documents will be reviewed regularly for completeness and specifically cross-checked with quarterly report and invoice information directly by program leadership prior to submission. This process will be led by the Vice President of Family Empowerment and Self Sufficiency with support from operational and compliance staff.

View Audit 368880 Questioned Costs: $1

Finding 1156531 (2024-001)

Material Weakness 2024

Cornerstones Inc, Cornerstones Housing Corporation & Rihc Partners, Lp

VA

Eligibility Internal Control / Segregation of Duties § 200.303 § 200.334

anagement agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. All program staff will receive updated training on eligibility requirements, supporting documents to track su...

anagement agrees with the recommendation and will implement stronger processes to ensure that records confirming the eligibility of program participants are obtained and properly maintained. All program staff will receive updated training on eligibility requirements, supporting documents to track such requirements, and supports throughout the year to ensure eligibility requirements are met and documented. Documents will also be reviewed regularly to ensure completeness against eligibility requirements. This process will be led by the Vice President of Family Empowerment and Self Sufficiency with support from operational and compliance staff.

View Audit 368880

Finding 1156525 (2024-001)

Material Weakness 2024

Sustainable Fisheries Partnership Foundation

HI

Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025

View Audit 368873

Finding 1156515 (2024-001)

Material Weakness 2024

Texas Biomedical Research Institute

TX

Cash Management Subrecipient Monitoring § 200.303 § 200.305

Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days ...

Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. In 18 instances, Texas Biomed paid subrecipients after 30 days of receipt of the request for reimbursement from the subrecipient, resulting in noncompliance with 2 CFR 200.305(b)(3). Corrective Action Plan: Effective June 1, 2023 Texas Biomed implemented enhanced controls to ensure timely entry of subrecipient invoices into the financial system and timely approvals by Principal Investigators (PIs) of invoices. While these controls were operating effectively after the implementation date, turnover within the Accounts Payable team had not been anticipated and led to delayed payment processing. In mid-2024, Texas Biomed implemented a new electronic AP/invoice system as part of a comprehensive Enterprise Resource Planning system (and associated supporting systems) conversion to enhance efficiencies and functionality. With implementation of new systems, control enhancements enabled by the systems were implemented. This included setting up subawards as Purchase Orders, which enabled automation of a previously manual process to secure PI approval of invoices. Accounts Payable staff have been trained on how to properly enter subaward invoices into the system to trigger electronic routing to the PI for approval. While these steps will streamline the approval process, a further mitigating control will be implemented, with Accounts Payable staff periodically tracking approvals of pending subrecipient invoices and notifying the appropriate Sponsored Program Administrator for follow up with PIs in the event of delayed approvals. Responsible Parties: Eva Zepeda, Director, Finance; Michelle Hyde, Controller Completion Date: September 30, 2024

View Audit 368866

Finding 1156514 (2024-002)

Material Weakness 2024

Texas Biomedical Research Institute

TX

Questioned Costs Procurement, Suspension & Debarment § 200.1 § 200.303 § 200.317 § 200.318 § 200.319

Finding 2024-002 – Procurement and Suspension and Debarment Condition: Texas Biomed did not comply with procurement requirements per the Uniform Guidance. Specifically, Texas Biomed did not comply with informal procurement methods for small purchases and noncompetitive procurement requirements. Texa...

Finding 2024-002 – Procurement and Suspension and Debarment Condition: Texas Biomed did not comply with procurement requirements per the Uniform Guidance. Specifically, Texas Biomed did not comply with informal procurement methods for small purchases and noncompetitive procurement requirements. Texas Biomed also did not comply with its own procurement policy in relation to procurements of small purchases and noncompetitive procurements. Additionally, Texas Biomed did not maintain records for certain procurements sufficient to detail the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, the basis for the contract price, and the performance of a cost or price analysis, when required. Three of the four procurements noted as findings were, in fact, sole source procurements but lacked timely documentation of sole source rationale. Corrective Action Plan: Texas Biomed made a change in management over the procurement function and hired an experienced and knowledgeable Assistant Director of Supply Chain Management on September 15, 2025 to oversee procurement and ensure compliance with the necessary requirements. To ensure compliance and adherence to purchasing policies and procedures, Texas Biomed will introduce a Purchasing Compliance Program. This program will include training and oversight procedures for the purchasing program. The training will include: new hire training, ongoing quarterly purchasing training for end users and purchasing staff. The purchasing team will maintain training documents and ensure new and existing employees have the most current policy, procedures, and requirements to guide them through the purchasing process. The oversight procedures will be performed by the Assistant Director of Supply Chain Management and shall include auditing purchase orders over the micro-purchase threshold to ensure proper documentation is present. The Assistant Director of Supply Chain Management will also lead efforts of continuous improvement to update and communicate the Purchasing Compliance Program to all Texas Biomed staff. Key dates shall include: • Enhanced new hire training October 2025 • Quarterly training session January 2026 • Oversight procedures developed November 2025 Responsible Parties: Eva Zepeda, Director, Finance; Eric McGowin, Assistant Director, Supply Chain Management Completion Date: October 31, 2025

View Audit 368866 Questioned Costs: $1

Finding 1156477 (2024-002)

Material Weakness 2024

Lifewire

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.430

Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...

Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.

View Audit 368819

Finding 1156474 (2024-001)

Material Weakness 2024

Lifewire

WA

Subrecipient Monitoring HUD Housing Programs Reporting § 200.303

Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental...

Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental payment request made with public funds. LifeWire’s AP approval process requires review and approval by members of the Director team before payments can be issued. In 2025, all rental payments made with CoC funds now have documented evidence of internal approval and review. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: The new process was rolled out in November 2024.

View Audit 368819

Finding 1156454 (2024-002)

Material Weakness 2024

Connections to Success

MO

Cash Management Reporting Significant Deficiency § 200.303

Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create...

Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create an internal control for drawdown request and report approval and review. The Organization should ensure these policies are followed for all drawdowns, reports and that documentation related to these policies are maintained. Views of Responsible Officials: Management agrees with the finding and recommendation. To address this, the Organization will update its Cash Management Policy to implement a documented, two-level review and approval process for all drawdown requests and reports, requiring both preparer and approver sign-off and develop a standard checklist to ensure each drawdown is supported by allowable, documented expenditures prior to submission. The Grants Manager will conduct quarterly internal reviews to ensure this process is being followed. Contact information for this finding: If the U.S. Department of Labor has questions regarding this schedule, please call Brandi Janke at (816) 520-4404. Completion Date: September 2025

View Audit 368768

Finding 1156380 (2024-005)

Material Weakness 2024

9/11 Day

CA

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.332

The subgrantees in question were Boys & Girls Clubs of America, National Youth Service League, Young Men’s Service League, and Boise State. 9/11 Day researched all subgrantees, required each to provide MOUs, program details, and budgets, and verified organizational status using resources such as Can...

The subgrantees in question were Boys & Girls Clubs of America, National Youth Service League, Young Men’s Service League, and Boise State. 9/11 Day researched all subgrantees, required each to provide MOUs, program details, and budgets, and verified organizational status using resources such as Candid and Charity Navigator. Financial statements were also reviewed, but documentation of these reviews and verifications was not consistently retained, and certain federal requirements were not fully incorporated into the process. 9/11 Day has now adopted a written policy that ensures that, in its role as a pass-through entity, all subgrants will be made in full compliance with the minimum required elements found under 2 CFR 200.332(b). This shall include implementing a comprehensive tracking and monitoring system for all subgrantees, regardless of funding level, with enhanced verification requirements for those receiving over $30,000. All subaward agreements will be updated to include the minimum required elements under 2 CFR 200.332(b), and the evaluation of subgrantee risk will incorporate all suggested elements under 2 CFR 200.332(c), including consideration of fraud risk and risk of noncompliance. The system will record the time and date of all eligibility verifications and retain supporting documentation, including MOUs, SAM.gov confirmation of suspension and debarment status, IRS Form 990s, financial statements, and audit confirmations. In compliance with 2 CFR 200.332(e)(1), subgrantees will now be required to submit both performance and financial reports, which will be reviewed and compared against project budgets. In addition, 9/11 Day will evaluate subgrantees’ Single Audits, if filed, in accordance with 2 CFR 200.332(e)(2)–(4) and will review any reported deficiencies. All monitoring activities will be documented and logged throughout the life of each project to ensure stronger oversight, complete documentation, and compliance with federal requirements.

View Audit 368692

Finding 1156379 (2024-004)

Material Weakness 2024

9/11 Day

CA

Questioned Costs Subrecipient Monitoring Reporting § 200.303 § 200.328 § 200.329

In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a ...

In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a centralized tracking log, and for those receiving pass-through funds exceeding $30,000, the required reporting will be completed directly in SAM.gov, which now includes the Federal Subaward Reporting System (FSRS). Each subgrantee’s eligibility will be verified in SAM.gov, with the date and results of the verification recorded, and all supporting documentation retained on file. This corrective action ensures that all subawards are properly logged, reported, and compliant with FFATA requirements.

View Audit 368692 Questioned Costs: $1

Finding 1156378 (2024-003)

Material Weakness 2024

9/11 Day

CA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.327

Following the close of the 2023 audit in October 2024, 9/11 Day implemented a strengthened procurement process for all large vendors, including the adoption of a formal procurement policy that complies with federal guidelines. A vendor log and checklist system has been established to document the re...

Following the close of the 2023 audit in October 2024, 9/11 Day implemented a strengthened procurement process for all large vendors, including the adoption of a formal procurement policy that complies with federal guidelines. A vendor log and checklist system has been established to document the receipt of RFPs, the rationale and method of procurement, and decisions on whether to move forward with a vendor. Although 9/11 Day has, and does verify whether vendors and subgrantees are permitted to receive federal funds, we have now updated our policy to retain printed verification of each vendor’s/subgrantee’s eligibility to receive federal funds, including confirmation that these organizations are not suspended or debarred. These documents will be retained in the procurement file for each vendor/subgrantee. These steps ensure compliance with 2 CFR 200.318 and provide clear documentation and oversight for all procurement activities.

View Audit 368692

Finding 1156332 (2024-002)

Material Weakness 2024

Rural Development Finance Corporation

ND

Internal Control / Segregation of Duties § 200.303

Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant report...

Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management will begin having another review and approve grant reimbursement requests and grant reporting prior to submission. Completion Date Rural Development Finance Corporation will implement the plan in 2025.

View Audit 368624

Finding 1156330 (2024-010)

Material Weakness 2024

McR Health, Inc.

FL

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...

MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.

View Audit 368617 Questioned Costs: $1

Finding 1156308 (2024-003)

Material Weakness 2024

Northshore University Healthsystem

IL

Subrecipient Monitoring Cash Management § 200.303 § 200.305

Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subr...

Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subrecipient. This includes implementation of the following preventative controls to ensure that payments are made within the required timeline: a. Active communications with Principal Investigators of subawards on invoice approval timeline at award initiation and creation of procedures for documenting and advising OSP of invoices requiring correction and /or modification. b. Work with Post Award Staff to ensure that adequate documentation is created and maintained related to the follow-up that occurs when issues are being investigated and resolved that cause a delay in invoice processing.c. Development and utilization of a report for internal reporting and tracking of pending sub-invoices payments approaching the 30-day deadline. d. Implementation of the Invoice Receipt Date as a required field for subaward invoicing in Workday rather than the optional field it is at present. Responsible Official: Cate Ekstrom, Director of Research

View Audit 368577

Finding 1156243 (2024-001)

Material Weakness 2024

Northshore University Healthsystem

IL

Reporting § 200.303 § 200.502 § 200.510

Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseases...

Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseasesManagement will distribute the updated SEFA reporting policy and procedure, outlining the required reporting requirements and timelines. A SEFA preparation checklist will be implemented to ensure that all submissions are accurate and complete. At the end of the year, Finance and Grants Management will collaborate to review all grant activities to ensure proper inclusion in the SEFA.Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health

View Audit 368577

Finding 1156218 (2024-001)

Material Weakness 2024

Marshfield Clinic Health System, Inc.

WI

Reporting Allowable Costs / Cost Principles Cash Management § 200.303

Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...

Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026

View Audit 368574

Finding 1156215 (2024-002)

Material Weakness 2024

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...

Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024

View Audit 368574

Finding 1156126 (2024-001)

Material Weakness 2024

Oregon Child Development Coalition, Inc.

OR

Reporting Internal Control / Segregation of Duties § 200.303

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2024-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should reevaluate the established organizational controls regarding federal financial reporting to ensure that such policies and proc...

FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2024-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should reevaluate the established organizational controls regarding federal financial reporting to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action taken in response to finding: The finding was recognized by management as an out of the ordinary deficiency of internal controls experienced during a period of financial staff turnover. Action Plan: A written procedure will be developed to ensure that documentation of oversight is performed prior to the certification of federal financial reporting. Training will be provided to staff with oversight responsibilities. Name(s) of the contact people responsible for correction action: Donalda Dodson, Chief Executive Officer Plan completion date for corrective action plan: November 30, 2025

View Audit 368545

Finding 1156122 (2024-003)

Material Weakness 2024

Clay County

MN

Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: As part of the recent audit of...

Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: As part of the recent audit of MAXIS Medical Assistance eligibility determinations, Clay County Social Services recognizes that errors were found in several case files. In response, eligibility workers will receive targeted training on timely and accurate case entry in MAXIS, with particular emphasis on the verification and documentation of citizenship, income, and assets in accordance with OHS policy. The lead worker for this program will conduct random case reviews monthly, in addition to 3 case reviews for each worker around their annual performance evaluation. These case reviews will be reviewed with the worker thoroughly, coaching provided if necessary, and any errors found will be corrected. The supervisor will retain these case reviews and analyze them for patterns and provide team training and guidance as appropriate. For staff with repeated errors, performance management will be enacted in the form of verbal coaching, performance improvement plans, etc. The Health Care Team supervisor will strengthen internal procedures to reinforce documentation and timeliness standards, review results from case reviews on a regular basis, and initiate corrective performance measures when patterns of errors are observed. In addition, annual training on eligibility documentation will also be incorporated into the department's training plan. Anticipated Completion Date: Refresher training for eligibility workers and thorough review of 2024 audit findings both individually and as a group: completed on August 7, 2025 Case reviews by lead worker: Already implemented at the time of this 'writing and ongoing January 2026 and ongoing: Health Care supervisor begins quarterly reviews of audit findings and reports results to department leadership. January 2026 and ongoing: Annual eligibility documentation training incorporated into the department training calendar.

View Audit 368538

Finding 1156121 (2024-002)

Material Weakness 2024

Clay County

MN

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services ack...

Finding Number: 2024-002 Finding Title: Eligibility - METS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: Clay County Social Services acknowledges the audit finding that in 2 of the 40 METS Medical Assistance eligibility case files reviewed, required documentation was either missing or not properly recorded. To address this, all eligibility workers will receive refresher training on documentation standards, with a focus on citizenship and income verification requirements. The lead worker for this program will conduct random case reviews monthly, in addition to 3 case reviews for each worker around their annual performance evaluation. These case reviews will be reviewed with the worker thoroughly, coaching provided if necessary, and any errors found will be corrected. The supervisor will retain these case reviews and analyze them for patterns and provide team training and guidance as appropriate. For staff with repeated errors, performance management will be enacted in the form of verbal coaching, performance improvement plans, etc. In addition, annual training on eligibility documentation, specifically around citizenship status, will be added to the Division's training plan. Progress will be tracked through internal audits and summarized for leadership review. These actions are intended to ensure all required documentation is properly obtained, verified, and recorded in METS, thereby strengthening internal controls, reducing the risk of ineligible individuals receiving benefits, and improving future audit compliance. Anticipated Completion Date: Refresher training for eligibility workers and thorough review of 2024 audit findings both individually and as a group: completed on August 7, 2025 Case reviews by lead worker: Already implemented at the time of this writing and ongoing Review and reporting to leadership: Beginning January 1, 2026 and ongoing Annual training incorporated into department plan: Effective December 1, 2025

View Audit 368538

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