Corrective Action Plans

Finding 1224517 (2025-004)

Material Weakness 2025

NC

Allowable Costs / Cost Principles Reporting § 200.512

Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have...

Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have been maxed out, including Finance staff trying to balance regular duties, audit fieldwork and disaster related responsibilities. 180 Corrective Action Plan (continued) We completed the FY24 audit at the end of September 2025 and immediately began the FY25 process. With systems implemented over the last two years, we were able to complete all year-end reconciliations and FY25 audit fieldwork in approximately seven months. This has been the most efficient completion of an audit for Transylvania since FY19, reflecting the effectiveness of these changes. Procedures to reconcile subsidiary ledgers monthly have been implemented as an ongoing responsibility of the Finance Director and Accountant to minimize year-end adjustments. The Finance Director has also completed over 50 hours of CPE through the School of Government to support continued process improvement. Communication between the auditor and the County has remained open throughout this period of transition and disaster management. Proposed Completion Date: Immediately.

View Audit 407756

Finding 1224516 (2025-003)

Material Weakness 2025

Transylvania County

NC

Internal Control / Segregation of Duties

Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports...

Name of Contact Person: Nathanael Carver Management Response: In FY24, the County’s Information Technology Department implemented enhanced procedures under the Computer and Internet Use Policy to strengthen the security of County and State data. These updates include restricting unused network ports, limiting network access by non-County devices, enforcing stronger password requirements, and requiring all IT-related support requests to be submitted through a centralized ticketing system. Automatic time-out procedures were implemented across all County workstations. In addition, staff were reminded of their responsibility to secure workstations when unattended. Compliance is reinforced through random verification checks conducted by DSS supervisors and IT staff to confirm users have properly logged out of their workstations. Further review identified that the specific instance in question involved a workstation assigned to a contracted worker. In response, targeted training was provided to both the contractor and the contracting organization to ensure a clear understanding of County security expectations and procedures. These actions demonstrate the County’s commitment to strengthening controls, addressing identified gaps, and maintaining ongoing compliance with data security requirements. Proposed Completion Date: Immediately

View Audit 407756

Finding 1224496 (2025-003)

Material Weakness 2025

City of Pittsburg, Kansas

KS

Procurement, Suspension & Debarment

Management’s Response/Corrective Action Plan (Unaudited) – Management acknowledges the finding. The City has reviewed and updated its written procedures to require that evidence of suspension and debarment checks (e.g., SAM.gov search results, vendor certifications, or contract clauses) be saved in ...

Management’s Response/Corrective Action Plan (Unaudited) – Management acknowledges the finding. The City has reviewed and updated its written procedures to require that evidence of suspension and debarment checks (e.g., SAM.gov search results, vendor certifications, or contract clauses) be saved in the SUSPENSION-DEBARMENT CHECKS file at the time of verification. The new ERP system has project accounting, grant accounting, and contract accounting modules that allow tracking of the certification numbers/SAM.gov number, etc. Staff have been trained on these requirements and procedures to ensure documentation is consistently maintained for all covered transactions in accordance with federal guidelines. Planned Completion Date – These modifications are being implemented immediately. Contact Person Responsible for Correction Action – Finance Director

View Audit 407749

Finding 1224495 (2025-002)

Material Weakness 2025

Scott County

MN

Subrecipient Monitoring Matching / Level of Effort / Earmarking Eligibility

Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed ...

Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that supervisors will properly follow up with staff during casefile review and will retain documentation supporting that evaluation. Name of the contact person responsible for corrective action: Steven Jones Planned completion date for corrective action plan: December 31, 2026

View Audit 407746

Finding 1224494 (2025-002)

Material Weakness 2025

COMMONWEALTH CENTER FOR ADVANCED MANUFACTURING

VA

Reporting Internal Control / Segregation of Duties

2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to ena...

2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to enable accurate monitoring and tracking of accumulated expenditures on a fiscal year basis so we can timely determine if the Organization meets the threshold for a Single Audit.

View Audit 407744

Finding 1224489 (2025-001)

Material Weakness 2025

COMMONWEALTH CENTER FOR ADVANCED MANUFACTURING

VA

Allowable Costs / Cost Principles Reporting

2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the...

2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the year, the Organization should retain records of these operating effectively. Action Taken: We have reviewed our required documentation submission process and updated it to require capture of proof of documentation submission.

View Audit 407744

Finding 1224484 (2025-012)

Material Weakness 2025

Anna Comm Cons School District 37

IL

Allowable Costs / Cost Principles Cash Management Equipment & Real Property Management

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois Sch...

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois School Board of Education for these unallowed expenditures. Corrective Action: The District will ensure that all costs charged to the Title I grant are allowable per the grant agreement going forward.

View Audit 407741

Finding 1224483 (2025-011)

Material Weakness 2025

Anna Comm Cons School District 37

IL

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Imm...

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Immediately.

View Audit 407741

Finding 1224482 (2025-010)

Material Weakness 2025

Anna Comm Cons School District 37

IL

Reporting

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-a...

Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-annual certifications of time and effort distribution records. Proposed Completion Date: Fiscal year 2026.

View Audit 407741

Finding 1224472 (2025-001)

Material Weakness 2025

Fisk University

TN

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

2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...

2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 407740

Finding 1224469 (2025-002)

Material Weakness 2025

Fisk University

TN

Allowable Costs / Cost Principles Subrecipient Monitoring

2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes th...

2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes the importance of maintaining complete and readily accessible documentation to support all federal expenditures in accordance with institutional policy and federal compliance requirements. The University will reinforce documentation and record retention requirements with all relevant personnel, including finance staff, grant administrators, and principal investigators. Additionally, management will implement enhanced controls to ensure that all required supporting documentation is properly maintained and centrally accessible. This will include transitioning toward a more standardized and, where feasible, electronic document management process to reduce the risk of missing records. Furthermore, periodic monitoring procedures will be established, including routine reviews of disbursement files to confirm the presence of required supporting documentation. Any identified deficiencies will be promptly addressed, and corrective actions will be taken to prevent recurrence. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 407740

Finding 1224468 (2025-003)

Material Weakness 2025

Fisk University

TN

Cash Management Period of Performance Subrecipient Monitoring

2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and ...

2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and drawdowns is critical to ensuring compliance with federal requirements governing grant periods. To Strengthening Grant Closeout Procedures management will establish a formal grant closeout timeline to begin 90 days prior to the award end date, require principal investigators (PIs) and grant administrators to review all outstanding obligations and ensure timely submission of final expenses and implement a standardized closeout checklist to confirm all costs are recorded within the allowable period To Enhanced Monitoring of Grant Periods management will develop and maintain a centralized tracking system for all federal awards, including start and end dates, generate monthly reports identifying grants nearing expiration (within 90, 60, and 30 days) and distribute reports to Pis, Grants Accounting, and Finance leadership for proactive management. For timely processing and drawdown controls management will require all invoices and expenditures to be submitted within a defined timeframe (e.g., within 30 days of service or project completion), establish internal deadlines for processing disbursements and drawdowns prior to the grant end date and implement a review step within Grants Accounting to verify that expenses fall within the period of performance before payment is released. The grants department will conduct mandatory training for PIs, grant managers, and finance staff on period of performance requirements and federal compliance expectations and reinforce accountability for timely submission and processing of expenditures Management will also put in place for any costs identified outside the period of performance will require, documented justification, review and approval by the Director of Grants Accounting and CFO, and verification of allowability under award terms or sponsor approval, if applicable. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026

View Audit 407740

Finding 1224465 (2025-001)

Material Weakness 2025

The Metrohealth System

OH

Subrecipient Monitoring Reporting § 200.303

Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Acti...

Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Action: Management concurs with this recommendation. MetroHealth will establish and maintain a log documenting FFATA report submission, with internal reviews of disclosures prior to submission Contact person responsible for corrective action: Michele Benos, Manager, Grants Accounting and Brynna Baird, Manager, Sponsored Programs Anticipated Completion Date: 05/31/2026

View Audit 407736

Finding 1224391 (2025-002)

Material Weakness 2025

Fraser

MN

Cash Management Significant Deficiency § 200.303

Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement reques...

Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement request prior to submission. Responsible Individuals: Jim Strickland, Jim Olson Corrective Action Plan: We have designated a member of management to review more extensively reimbursement requests at a more detailed level prior to submission. Anticipated Completion Date: Already in place

View Audit 407730

Finding 1224390 (2025-001)

Material Weakness 2025

Fraser

MN

Reporting Significant Deficiency § 200.303

Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Resp...

Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Responsible Individuals: Lucas Kunach, Miranda Gilmore, Jim Olson Corrective Action Plan: We have designated a member of management to review the reporting materials prior to submission for accuracy and tie to detail support. Anticipated Completion Date: Already in place

View Audit 407730

Finding 1224389 (2025-001)

Material Weakness 2025

American Society of Clinical Oncology, Inc.

VA

Subrecipient Monitoring Reporting § 200.502 § 200.510

Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorr...

Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorrect de minimis indirect cost rate was used and charged to a federal award. - Approximately $65,000 of federal expenditures were omitted from the initial SEFA. - Subrecipient costs from the prior year were charged to the current year due to incomplete accruals in the prior year. As a result, the SEFA was not complete or accurate prior to submission for audit. Planned Corrective Action: Management concurs with the findings and related recommendations. While the Organization completed its federal award activity in May 2025 and does not currently anticipate additional federal award activity, it recognizes the importance of compliance with grant reporting requirements, including the accurate preparation of the Schedule of Expenditures of Federal Awards (SEFA). In response to this finding, the Organization has taken the following corrective actions: Indirect Cost Rate: Updated our grant setup checklist to ensure the correct de minimis indirect cost rate is applied. The Organization has initiated and is currently processing the repayment of the overcharged indirect costs to the primary awardee. SEFA Completeness & Year-End Cutoff: Implemented a formal year-end SEFA reconciliation procedure. This includes a secondary review by the Director, Accounting to cross-reference general ledger federal expenditures against grant award agreements and to verify that all subrecipient accruals are recorded in the proper fiscal period. These improvements in our review and approval functions are designed to prevent future reporting omissions and ensure timely, accurate SEFA preparation should the Organization be subject to Single Audit requirements in the future. Anticipated Completion Date: July 31, 2026 Name of Contact Person: Melinda O’Leary, Chief Financial Officer & Vice President If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Melinda O’Leary, Chief Financial Officer & Vice President at 571-483-1324.

View Audit 407716

Finding 1224388 (2025-003)

Material Weakness 2025

Platte County, Nebraska

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

The Platte County has implemented procedures to ensure when an entity is selected by Board Resolution/Motion, to be paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented. The procedure to have the entity verif...

The Platte County has implemented procedures to ensure when an entity is selected by Board Resolution/Motion, to be paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented. The procedure to have the entity verified is included in the Board minutes.

View Audit 407712

Finding 1224387 (2025-002)

Material Weakness 2025

Platte County, Nebraska

NE

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in Decem...

After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in December 2025.

View Audit 407712

Finding 1224384 (2025-001)

Material Weakness 2025

Carver County

MN

Eligibility Reporting Significant Deficiency § 200.303

Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit ...

Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026

View Audit 407704

Finding 1224381 (2025-001)

Material Weakness 2025

Housing Authority of the City of Royston

GA

Cash Management HUD Housing Programs

2025-001 – ALN 14.872 – Public Housing Capital Fund Program – Period of Performance The Authority has developed and implemented the necessary standard operating procedures to verify the timing of drawdowns relative to obligations and actual payments and periodically review drawdown and expenditure r...

2025-001 – ALN 14.872 – Public Housing Capital Fund Program – Period of Performance The Authority has developed and implemented the necessary standard operating procedures to verify the timing of drawdowns relative to obligations and actual payments and periodically review drawdown and expenditure records to proactively identify and correct discrepancies. Person Responsible for Correction of Finding: Krista Bolemon, Executive Director Projected Completion Date: December 31, 2026

View Audit 407697

Finding 1224380 (2025-004)

Material Weakness 2025

Kentucky Health Department Association

KY

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.305

KHDA will hire a CPA to oversee this process.

View Audit 407695

Finding 1224379 (2025-003)

Material Weakness 2025

Kentucky Health Department Association

KY

Cash Management § 200.305

KHDA will hire a CPA to oversee this process.

View Audit 407695

Finding 1224378 (2025-002)

Material Weakness 2025

Kentucky Health Department Association

KY

Procurement, Suspension & Debarment § 200.206

Regarding the debarment status, the Policy has been updated to include that and says : Compliance with this Policy. KHDA Management shall maintain oversight to ensure that contractors and vendors perform in accordance with the terms, conditions, and specifications of contracts or purchase orders. Vi...

Regarding the debarment status, the Policy has been updated to include that and says : Compliance with this Policy. KHDA Management shall maintain oversight to ensure that contractors and vendors perform in accordance with the terms, conditions, and specifications of contracts or purchase orders. Violations of this policy may result in disciplinary action, up to and including termination. KHDA will hire a CPA firm to oversee this process.

View Audit 407695

Finding 1224372 (2025-005)

Material Weakness 2025

City of Woodland

CA

Reporting Internal Control / Segregation of Duties Procurement, Suspension & Debarment

The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the ...

The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff are exploring options for third party assistance with financial reporting functions.

View Audit 407679

Finding 1224366 (2025-001)

Material Weakness 2025

On Point Nyc, Inc.

NY

§ 200.512

Additional time was needed to complete accurate fiscal records for the year ended June 30, 2025. Monthly closings and fiscal records reconciliations for the year ending June 30, 2026, are timely being conducted. Timely filing of the Data Collection form for the year ended June 30, 2026 is anticipate...

Additional time was needed to complete accurate fiscal records for the year ended June 30, 2025. Monthly closings and fiscal records reconciliations for the year ending June 30, 2026, are timely being conducted. Timely filing of the Data Collection form for the year ended June 30, 2026 is anticipated.

View Audit 407678

Corrective Action Plans

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