Corrective Action Plans

Finding 1155071 (2024-004)

Material Weakness 2024

City of Gary

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2004-004 Finding Subject: Congressional Recommended Awards-Procurement and Suspension, and Debarment Contact Person Responsible for Corrective Action: Police Chief Derrick Cannon Contact Phone Number and Email Address: 219-881-1214 View of Responsible Officials: We Concur Description of Corr...

FINDING 2004-004 Finding Subject: Congressional Recommended Awards-Procurement and Suspension, and Debarment Contact Person Responsible for Corrective Action: Police Chief Derrick Cannon Contact Phone Number and Email Address: 219-881-1214 View of Responsible Officials: We Concur Description of Corrective Action Plan: The Gary Police Department intends to make the following corrections moving forward with Procurement, Suspension and Debarment: We will make sure that the City of Gary Policies and Procedures have been reviewed and outlined prior to any purchases. While we ensure that the vendor who will supply the request has been properly vetted and all paperwork prior has been submitted. This includes, but not limited to a printed copy of report the System for Award Management (SAM) Excluded Parties List System (EPLS) if applicable, collecting a certification from the person or the entity. In partnership, Chief Derrick Cannon Chief Derrick Cannon City of Gary Anticipated Completion Date: February 2026

View Audit 367388

Finding 1155070 (2024-003)

Material Weakness 2024

City of Gary

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Respon...

FINDING 2004-003 Finding Subject: CDBG – Entitlement Grants Cluster – Internal Control – Reporting Contact Person Responsible for Corrective Action: LaTrea Reed Contact Phone Number and Email Address: 219-881-5085 View of Responsible Officials: We Concur Description of Corrective Action Plan: Response to Finding: Segregation of Duties and Oversight of Required FFATA Reporting To address the finding related to segregation of duties and the lack of an established oversight or review process for required reports submitted under the Federal Funding Accountability and Transparency Act (FFATA), the Department of Community Development will implement a formalized review process. This process will include the use of a signature form to document the roles of the: • Preparer – responsible for compiling the report, • Reviewer – responsible for independently verifying the report’s accuracy, and • Submitter – responsible for final submission of the verified report. All parties will be required to sign the form upon completion of their respective responsibilities, ensuring accountability, verification of data accuracy, and compliance with FFATA reporting requirements. Anticipated Completion Date: February 2026

View Audit 367388

Finding 1155068 (2024-002)

Material Weakness 2024

City of Kokomo

IN

Reporting § 200.302 § 200.303 § 200.328 § 200.329 § 200.334

Finding 2024-002 Finding Subject: Economic Development Cluster – Reporting Summary of Finding: Material Weakness, Other Matters The data submitted in the SF-425 report submitted by the city for the reporting period ending on 9/30/24 contained the following errors: • Cash Receipts Understated by $1,0...

Finding 2024-002 Finding Subject: Economic Development Cluster – Reporting Summary of Finding: Material Weakness, Other Matters The data submitted in the SF-425 report submitted by the city for the reporting period ending on 9/30/24 contained the following errors: • Cash Receipts Understated by $1,037,155 • Cash Disbursements Understated by $1,037,155 The lack of internal controls and noncompliance was isolated to the award 06-79-06420 EDA-Davis Road Construction project. Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number and Email Address: 765-456-7380 wreed@cityofkokomo.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: City of Kokomo will design and implement a procedures where the Federal Financial Report and the Quarterly progress report will be reviewed by the director of development to ensure that there is oversight and that the report is complete and accurate. Anticipated Completion Date: December 31, 2025

View Audit 367387

Finding 1155067 (2024-003)

Material Weakness 2024

Pembina County Housing Authority

ND

HUD Housing Programs

Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025.

View Audit 367379

Finding 1155066 (2024-002)

Material Weakness 2024

Pembina County Housing Authority

ND

HUD Housing Programs Internal Control / Segregation of Duties

Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2025.

View Audit 367379

Finding 1155065 (2024-001)

Material Weakness 2024

Pembina County Housing Authority

ND

HUD Housing Programs Eligibility

Contact Person Tawnya T, Executive Director Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff. Planned Completion Date for CAP December 31, 2025.

View Audit 367379

Finding 1155064 (2024-007)

Material Weakness 2024

Muskogee County

OK

Reporting

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant a...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the new county grant administrator to ensure proper grant administration.

View Audit 367369

Finding 1155063 (2024-006)

Material Weakness 2024

Muskogee County

OK

Questioned Costs Procurement, Suspension & Debarment

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant a...

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the new county grant administrator to ensure proper grant administration.

View Audit 367369 Questioned Costs: $1

Finding 1155062 (2024-005)

Material Weakness 2024

Muskogee County

OK

Internal Control / Segregation of Duties

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, an...

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements.

View Audit 367369

Finding 1155061 (2024-004)

Material Weakness 2024

Muskogee County

OK

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, an...

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements.

View Audit 367369

Finding 1155031 (2024-001)

Material Weakness 2024

Watts Healthcare Corporation

CA

Questioned Costs Subrecipient Monitoring Cash Management

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025

View Audit 367364 Questioned Costs: $1

Finding 1155029 (2024-001)

Material Weakness 2024

Bauer Family Resources, Inc.

IN

HUD Housing Programs Material Weakness Reporting

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house a...

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house and all partnerships with the outside accounting firm, Wipfli, have been terminated. This year and moving into the future, we do not anticipate having any issues with completing our audit on time. This audit for 2024 will be completed in a timely manner.

View Audit 367354

Finding 1155017 (2024-001)

Material Weakness 2024

Terrace Heights Sewer District

WA

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318

Finding ref number: 2024-001 Finding Caption: The District did not have adequate written internal controls in place to ensure compliance with federal procurement requirements.Name, address, and telephone of District contact person: Jeff Alderson 186 Iron Horse Court Suite 100 Yakima, WA 98901 509-45...

Finding ref number: 2024-001 Finding Caption: The District did not have adequate written internal controls in place to ensure compliance with federal procurement requirements.Name, address, and telephone of District contact person: Jeff Alderson 186 Iron Horse Court Suite 100 Yakima, WA 98901 509-453-8702 Corrective action the auditee plans to take in response to the finding: This was the Districts first experience with federal funding. We have practiced appropriate internal controls but neglected to have a written formal policy. Upon realizing that we needed a formal written policy we drafted the steps we utilized to procure our contractor and supplies. That draft was then brought through our commissioner’s approval process. It was accepted formally by our Board of Commissioners on May 2024. Anticipated date to complete the corrective action: Completed May 2024

View Audit 367342

Finding 1154988 (2024-001)

Material Weakness 2024

City of Redfield

SD

Internal Control / Segregation of Duties Material Weakness Reporting

When federal compliance issues arise, the City Finance Officer will communicate them to the Mayor

View Audit 367338

Finding 1154985 (2024-003)

Material Weakness 2024

American Indian Council on Alcoholism Inc.

WI

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.305 § 200.317 § 200.327 § 200.332

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFle...

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025

View Audit 367335

Finding 1154984 (2024-004)

Material Weakness 2024

American Indian Council on Alcoholism Inc.

WI

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional procurement policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person:...

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional procurement policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025

View Audit 367335 Questioned Costs: $1

Finding 1154981 (2024-009)

Material Weakness 2024

Silver Key Senior Services, Inc.

CO

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.516

Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controlle...

Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controller (new role in lieu of CFO) approvals will be maintained in writing, and transactions by the Controller will continue to be reviewed by the CEO. Quarterly spot checks will be conducted to confirm compliance. Anticipated Completion Date: Corrections were made as soon as the issue was identified; procedures are now in place to ensure consistent documentation

View Audit 367331

Finding 1154978 (2024-003)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.

View Audit 367318

Finding 1154977 (2024-002)

Material Weakness 2024

Elm Hill Water District

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.

View Audit 367318

Finding 1154976 (2024-001)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 367318

Finding 1154975 (2024-001)

Material Weakness 2024

Vhh - Jg Commons

WA

Cash Management HUD Housing Programs Reporting

Corrective Action: Management made a deposit for a total of $8,582 to cover the underfunded residual receipts. Management will maintain tracking record every year to ensure that the residual receipts account is appropriately funded. The bookkeeper will maintain the record and ensure that deposits ar...

Corrective Action: Management made a deposit for a total of $8,582 to cover the underfunded residual receipts. Management will maintain tracking record every year to ensure that the residual receipts account is appropriately funded. The bookkeeper will maintain the record and ensure that deposits are made as required.

View Audit 367316

Finding 1154973 (2024-010)

Material Weakness 2024

City of Opa Locka

FL

Allowable Costs / Cost Principles Reporting § 200.512

The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP’s are being reviewed with staff for implementation. This activity is ongoing. Responsible Party: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator The ab...

The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP’s are being reviewed with staff for implementation. This activity is ongoing. Responsible Party: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator The above corrective action plan is expected to be implemented in the next 12 months.

View Audit 367314

Finding 1154958 (2024-002)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.430 § 200.512

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and...

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154957 (2024-001)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.512

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of ...

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154955 (2024-003)

Material Weakness 2024

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.

View Audit 367288

Corrective Action Plans

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