Corrective Action Plans

Finding 1154140 (2024-001)

Material Weakness 2024

Day One

RI

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403 § 200.430

For payroll, procedures will be implemented to ensure that payroll costs allocated to federal grants are supported by actual time. For nonpayroll, procedures will be enhanced to ensure proper allocation of nonpayroll costs to federal grants. Allocations will be reviewed and monitored on a monthly an...

For payroll, procedures will be implemented to ensure that payroll costs allocated to federal grants are supported by actual time. For nonpayroll, procedures will be enhanced to ensure proper allocation of nonpayroll costs to federal grants. Allocations will be reviewed and monitored on a monthly and quarterly basis to prevent misallocation and ensure compliance with the Uniform Guidance. Personnel Responsible for Implementation: Executive Director Christy Zamani, and Beaulieu Accountancy Corporation Date of Implementation: August 5, 2025

View Audit 367067 Questioned Costs: $1

Finding 1154137 (2024-004)

Material Weakness 2024

American Association of Community Colleges

DC

Questioned Costs Subrecipient Monitoring Reporting

To address this finding, AACC will continue to request that all contracts be reviewed by the Chief Financial Officer prior to execution based on AACC’s Financial Policies and Procedures (page 25). Signed copies of the agreement will be held on file within the accounting department and the party exec...

To address this finding, AACC will continue to request that all contracts be reviewed by the Chief Financial Officer prior to execution based on AACC’s Financial Policies and Procedures (page 25). Signed copies of the agreement will be held on file within the accounting department and the party executing the agreement.

View Audit 367061 Questioned Costs: $1

Finding 1154136 (2024-003)

Material Weakness 2024

American Association of Community Colleges

DC

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318

To address this finding, AACC will adhere to the financial policies and procedures properly documenting procurement decisions for goods and services with a total cost of $25,000 or greater. (Financial Policies and Procedures, pages 25, 45). In the event of “Sole Service Providers”, staff will docume...

To address this finding, AACC will adhere to the financial policies and procedures properly documenting procurement decisions for goods and services with a total cost of $25,000 or greater. (Financial Policies and Procedures, pages 25, 45). In the event of “Sole Service Providers”, staff will document the circumstances as such for recording. Effective immediately, all projects will be reviewed by a team assembled within the association, (Staffing to be determined by the President/CEO). A staff member, housed in the President’s Office with research and using a scorecard, assess and present potential opportunities to the President/CEO for approval to proceed. Approved opportunities will be reviewed by the team along with the department head making the request. There will be a collaborative effort of the scope of the project along with the budget necessary to implement the project. All parties will sign-off on their respective steps prior to the full package being presented to the President/Chief Executive Officer for final approval. A checklist will be used to monitor the process. All vendors written into the agreement will be vetted through a process that will include the rationale for their selection.

View Audit 367061 Questioned Costs: $1

Finding 1154135 (2024-002)

Material Weakness 2024

American Association of Community Colleges

DC

Questioned Costs Subrecipient Monitoring § 200.332

To address this finding, AACC will adhere to the financial policies and procedures properly documenting the fraud risk assessments to determine the level of risk (Low, Medium, High), and will properly document all necessary monitoring procedures (Financial Policies and Procedures, pages 45-53). Addi...

To address this finding, AACC will adhere to the financial policies and procedures properly documenting the fraud risk assessments to determine the level of risk (Low, Medium, High), and will properly document all necessary monitoring procedures (Financial Policies and Procedures, pages 45-53). Additionally, AACC has developed a risk assessment policy that will accompany AACC’s Subrecipient Award and Monitoring Policy developed in 2021. The appropriate signatures and corrective action plans and follow up with be managed in a timely manner.

View Audit 367061 Questioned Costs: $1

Finding 1154134 (2024-001)

Material Weakness 2024

American Association of Community Colleges

DC

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.403

To address this finding, AACC will adhere to the financial policies and procedures requiring all necessary itemized information be submitted to accounting with the proper signatures for review and approval. (Financial Policies and Procedures, page 26) Additionally, a tracking document will be utiliz...

To address this finding, AACC will adhere to the financial policies and procedures requiring all necessary itemized information be submitted to accounting with the proper signatures for review and approval. (Financial Policies and Procedures, page 26) Additionally, a tracking document will be utilized by the project manager outlining all expenditure reporting and invoices for each of the sub-award recipients. This document will be reviewed during the meeting with the accounting services department for reconciliation with the transactions reported in AACC’s accounting systems. (Financial Policies and Procedures, page 42).

View Audit 367061 Questioned Costs: $1

Finding 1154133 (2024-005)

Material Weakness 2024

American Association of Community Colleges

DC

Allowable Costs / Cost Principles Reporting § 200.403

To Address this finding, AACC will adhere to the financial policies and procedures requiring all necessary itemized information be submitted to accounting with the proper signatures for review and approval. (Financial Policies and Procedures, page 26) Additionally, a tracking document will be utiliz...

To Address this finding, AACC will adhere to the financial policies and procedures requiring all necessary itemized information be submitted to accounting with the proper signatures for review and approval. (Financial Policies and Procedures, page 26) Additionally, a tracking document will be utilized by the project manager outlining all expenditure reporting and invoices for each of the sub-award recipients. This document will be reviewed during the meeting with the accounting services department for reconciliation with the transactions reported in AACC’s accounting systems. (Financial Policies and Procedures, page 42).

View Audit 367061

Finding 1154130 (2024-003)

Material Weakness 2024

Alvis, Inc.

OH

Reporting Internal Control / Segregation of Duties

We acknowledge the delay in submitting the 2023 audit to the Federal Audit Clearinghouse (FAC), which was caused by staffing shortages and reliance on audit-proposed adjustments that delayed audit completion in 2023. This was corrected in the 2024 audit period. We are confident these corrective acti...

We acknowledge the delay in submitting the 2023 audit to the Federal Audit Clearinghouse (FAC), which was caused by staffing shortages and reliance on audit-proposed adjustments that delayed audit completion in 2023. This was corrected in the 2024 audit period. We are confident these corrective actions taken in 2024 will prevent recurrence and restore our low-risk auditee status in future years.

View Audit 367060

Finding 1154129 (2024-002)

Material Weakness 2024

Alvis, Inc.

OH

Internal Control / Segregation of Duties Reporting

We acknowledge the auditor’s finding and agree that the prior period restatement was the result of insufficient internal oversight of Waiver billing activities previously managed by a third-party provider. Condition and Cause: The Organization relied on the expertise of a third-party billing special...

We acknowledge the auditor’s finding and agree that the prior period restatement was the result of insufficient internal oversight of Waiver billing activities previously managed by a third-party provider. Condition and Cause: The Organization relied on the expertise of a third-party billing specialist without adequate internal oversight. This led to the overstatement of Waiver services revenue over multiple years due to improper period recognition. Corrective Actions Taken and Planned: 1. Transition to In-House Billing: Alvis, Inc. has brought all Developmental Disabilities (DD) and Intermediate Care Facility (ICF) billing functions in-house. This transition provides greater control over billing accuracy, denial management, and revenue recognition. 2. Internal Oversight and Reconciliation: We have implemented internal review procedures to validate the accuracy and timing of all Waiver-related revenue. Monthly reconciliations are now conducted to ensure alignment between billing records and financial reporting. 3. Staff Training and Capacity Building: Internal staff have been trained in Medicaid Waiver billing practices and accrual-based revenue recognition to ensure proper oversight and compliance with GAAP. 4. Process Documentation and Controls: Billing workflows and internal controls have been documented and integrated into our financial close process to ensure timely and accurate reporting. Management is confident that these corrective actions will prevent recurrence and ensure the integrity of our financial statements going forward.

View Audit 367060

Finding 1154128 (2024-001)

Material Weakness 2024

Alvis, Inc.

OH

Reporting Internal Control / Segregation of Duties

Finding 2024-001 – Material Adjustments We acknowledge the finding and agree that the lack of timely reconciliations and reliance on audit adjustments indicated a breakdown in internal controls over financial reporting. Cause and Context: The root cause of this issue was primarily driven by the time...

Finding 2024-001 – Material Adjustments We acknowledge the finding and agree that the lack of timely reconciliations and reliance on audit adjustments indicated a breakdown in internal controls over financial reporting. Cause and Context: The root cause of this issue was primarily driven by the time spent unwinding the billing from the operational team and setting them up under the new Revenue Cyle Director position in the finance department. This department will now be directly responsible for the various Medicaid AR processes. Most of the material audit adjustments were the direct result of not having this group under the Finance department so proper determination could be made on the collection of these services. Corrective Actions Taken and Planned: 1. Moving all billing functions to the finance team: This team will be able to make quarterly adjustments to the Medicaid billing receivables. 2. Third party vendors: The finance team has established routine calls with our third-party billing partners to determine collectability throughout the year vs during the audit period. 3. Training and Oversight: The billing team has now created a weekly meeting / training cadence. 4. Revenue Cycle Management Enhancements: We have established an internal Billing and Revenue Cycle Management Team and developed a Centralized Intake Team to improve billing accuracy, eligibility verification, and reduce reliance on third-party vendors. These changes are expected to reduce write-offs and improve the integrity of our receivables. We are confident that these corrective actions will address the root causes of the finding and prevent recurrence. Management remains committed to maintaining strong internal controls and ensuring compliance with all applicable accounting standards. 5. In-House Billing for Specialized Services: Billing for Developmental Disabilities (DD) and Intermediate Care Facility (ICF) services have been brought in-house. This transition has resulted in a 14% increase in DD revenue and improved responsiveness to denials, client liability tracking, and continued stay approvals. These enhancements are designed to improve financial accuracy, reduce write-offs, and ensure timely and compliant revenue recognition. We are confident that these measures will prevent recurrence and strengthen the integrity of our financial reporting going forward.

View Audit 367060

Finding 1154127 (2024-001)

Material Weakness 2024

Willow Springs School District 108

IL

Reporting

The District will implement a process to track the submission time for the data collection form and single audit package.

View Audit 367057

Finding 1154122 (2024-001)

Material Weakness 2024

Housing Authority of the City of Torrington

CT

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and has already implemented procedures to correct the issue. The prior fee accountant that caused the late filing has been terminated and a new fee accountant has been hired. If there are questions regarding this correc...

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and has already implemented procedures to correct the issue. The prior fee accountant that caused the late filing has been terminated and a new fee accountant has been hired. If there are questions regarding this corrective action plan, please contact Ms. Claudia Sweeney, Executive Director at (860) 482-3581.

View Audit 367045

Finding 1154120 (2024-003)

Material Weakness 2024

Santa Fe Community Housing Trust

NM

Reporting Allowable Costs / Cost Principles Cash Management

View of Responsible Official The Housing Trust acknowledges the finding. Prior staffing and system limitations created gaps in tracking recycled funds and aligning general ledger data to SEFA. Since then: - A dedicated Finance Manager now oversees all financial activities. - A grant-specific chart o...

View of Responsible Official The Housing Trust acknowledges the finding. Prior staffing and system limitations created gaps in tracking recycled funds and aligning general ledger data to SEFA. Since then: - A dedicated Finance Manager now oversees all financial activities. - A grant-specific chart of accounts structure has been created in QBO. - Each grant now has a dedicated class and project for transaction tracking. - Recycled funds are being tracked separately from new funds in both QBO and the reimbursement log. - SEFA schedules will be reconciled monthly and reviewed with each billing cycle. Corrective Action Plan Timeline - Finalize and adopt new Grant Management Policies: by September 2025 - Implement monthly SEFA reconciliations: by September 2025 - Complete staff training on program income and federal grant tracking: by September 2025 Designated Employee Responsible for Corrective Action - Finance Manager - Assets Specialist Assistant - Accounting Technician

View Audit 367044

Finding 1154118 (2024-003)

Material Weakness 2024

Housing Authority of the City of Athens, Alabama

AL

HUD Housing Programs Special Tests & Provisions Material Weakness

We acknowledge the finding regarding the inadequate funding of the Reserve for Replacement account. The deficiency occurred due to lapses in internal controls over the timing and processing of required deposits, as managed by the independent accounting firm responsible for maintaining our books and ...

We acknowledge the finding regarding the inadequate funding of the Reserve for Replacement account. The deficiency occurred due to lapses in internal controls over the timing and processing of required deposits, as managed by the independent accounting firm responsible for maintaining our books and preparing monthly financial statements. In accordance with HUD Handbook 350.1, Chapter 4, Paragraph 4-13, which requires owners to make monthly deposits into the Reserve for Replacement account as specified in the Regulatory Agreement, the Ownership Entity has taken the following corrective actions: 1. – The accounting firm has been formally instructed, in writing, to include verification of the monthly reserve deposit as a standing item in their month-end close process and to provide evidence of the completed transfer with each monthly financial package. 2. Management Oversight – Ownership will review and sign off on the monthly reserve funding documentation before approving the financial statements for submission to the Board of Commissioners. 3. Quarterly Compliance Review – In addition to monthly monitoring, management will conduct a quarterly compliance review to ensure full adherence to HUD Handbook4350.1 requirements and the property's Regulatory Agreement.

View Audit 367032

Finding 1154117 (2024-002)

Material Weakness 2024

Housing Authority of the City of Athens, Alabama

AL

HUD Housing Programs Eligibility Significant Deficiency

The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in plac...

The property manager attended a couple of multifamily housing specialist training courses and received certification. The required update to the gross rents, annually based on the OCAF, will be corrected in tenants' files moving forward. The Housing Authority has put a quality control system in place to ensure the tenants' files are in compliance. We expect to be in compliance moving forward.

View Audit 367032

Finding 1154116 (2024-001)

Material Weakness 2024

Housing Authority of the City of Athens, Alabama

AL

HUD Housing Programs Cash Management Significant Deficiency

The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the t...

The outstanding balance currently reflected in the books represents unreconciled funds resulting from the transfer of assets and liabilities during the conversion of the Public Housing Program to the RAD Project-Based Rental Assistance (PBRA) Program. These funds were carried forward following the transition of ownership and operations from the PHA to Athens Housing Management, LLC, as the new ownership entity. By HUD RAD guidance, including the RAD Notice Revision 4 (H-2019-09/PIH-2019-23), when a public housing project converts to PBRA under RAD, the PHA is required to transfer assets and liabilities to the new ownership entity to ensure continuity and financial integrity of the property. Specifically, Attachment 1A to the RAD Notice outlines the obligation to transfer project-specific assets and liabilities from the public housing ledger to the new entity, including cash, receivables, and project-level obligations. The amounts in question were initially anticipated to be reconciled as part of that process. However, due to the complexity of the transition and lack of adequate internal controls at the time, the residual balance has remained unreconciled for the past five fiscal years. These amounts are not expected to be repaid or resolved in FY 2025. As such, this is a one-time, non-recurring issue, and corrective action is underway. Staff will formally seek HUD’s approval and submit a resolution to the Boards of both the Housing Authority (the management entity) and Athens Housing Management LLC (the ownership entity), requesting that the outstanding balance be written off. This action will appropriately clear the books of legacy items tied to the conversion and align the accounting records of both entities. This write-off recommendation aligns with best practices in governmental accounting for long-standing inter-entity balances that are no longer collectible or relevant to current operations. Additional internal controls have since been implemented to prevent recurrence, including improved cash management oversight, inter-entity reconciliation protocols, and timely financial reporting.

View Audit 367032

Finding 1154115 (2024-001)

Material Weakness 2024

Douglas County

WA

Procurement, Suspension & Debarment

Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective a...

Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Leah Hurd 140 19th St NW East Wenatchee, WA 98802 (509) 888-6595 Corrective action the auditee plans to take in response to the finding: Despite our best efforts, we have been unable to effectively implement controls ensuring purchases with federal dollars are compliant with suspension and debarment requirements. The County is developing federal procurement procedures, including purchase requests with a reminder to check suspension and debarment. We take this requirement seriously and will continue to work on systems until we have a fail-safe process. Anticipated date to complete the corrective action: 01/01/2026

View Audit 367027

Finding 1154107 (2024-001)

Material Weakness 2024

Brazos Valley Community Action Agency, Inc.

TX

Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties

U. S. Department of Health and Human Services Health Center Program – Assistance Listing No. 93.224/93.527 Recommendation: It is recommended that the Agency provide additional training to staff on the calculation and recording of sliding fee adjustments to ensure sliding fee adjustments are correctl...

U. S. Department of Health and Human Services Health Center Program – Assistance Listing No. 93.224/93.527 Recommendation: It is recommended that the Agency provide additional training to staff on the calculation and recording of sliding fee adjustments to ensure sliding fee adjustments are correctly applied to all eligible patients. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To address the eligibility compliance issues identified by CLA, the client will implement a corrective action plan centered on enhancing staff training and reinforcing procedural accuracy. All front-line and billing personnel will undergo targeted training sessions focused on the proper application of the Sliding Fee Scale (SFS) discount. This training will cover key eligibility criteria, including accurate income assessment against the 200% federal poverty level threshold, correct interpretation and application of CPT codes, and verification of insurance status prior to discount application. Special emphasis will be placed on real-world scenarios, such as identifying when a CPT code should be billed at no charge or when a patient’s insurance coverage disqualifies them from SFS eligibility. Name(s) of the contact person(s) responsible for corrective action: Jessica Rogers, Director of Finance. Planned completion date for corrective action plan: December 31, 2025.

View Audit 367021

Finding 1154105 (2024-004)

Material Weakness 2024

Village of Denmark

WI

Procurement, Suspension & Debarment Reporting

Uniform Grant Guidance Policies Recommendation: We recommend that the Village review the policies required by the Uniform Guidance, consider expected future federal funding levels and the potential for any future compliance audits required by federal uniform grant guidance, and also consider adoptin...

Uniform Grant Guidance Policies Recommendation: We recommend that the Village review the policies required by the Uniform Guidance, consider expected future federal funding levels and the potential for any future compliance audits required by federal uniform grant guidance, and also consider adopting appropriate policies to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action planned in response to finding: Management will evaluate federal uniform grant guidance requirements including expected future federal funding levels and the potential for any future compliance audits and develop an appropriate action plan moving forward. Name(s) of the contact person(s) responsible for corrective action: Sherri Konkol, Clerk / Treasurer Planned completion date for corrective action plan: Village began evaluating immediately and is in the process of determining the next action steps.

View Audit 367003

Finding 1154101 (2024-003)

Material Weakness 2024

Town of Oxford Connecticut

CT

Procurement, Suspension & Debarment Subrecipient Monitoring

FINDING 2024-003 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awar...

FINDING 2024-003 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: George Temple, First Selectman, (203) 888-2543 Ext. 3034 Projected Completion Date: June 30, 2025

View Audit 366990

Finding 1154097 (2024-001)

Material Weakness 2024

Technology for Rural Enhancement of Communities

SD

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Finding #2024-001: Activities Allowed or Unallowed Responsible Individual: Tiera Nikodym, Fiscal Specialist Corrective Action Plan: The Organization is aware of the finding and is working to develop a system to prevent future occurrences. Anticipated Completion Date: Current fiscal year

View Audit 366982

Finding 1154095 (2024-001)

Material Weakness 2024

The Carle Foundation

IL

Allowable Costs / Cost Principles

Corrected

View Audit 366981

Finding 1154089 (2024-002)

Material Weakness 2024

The Carle Foundation

IL

Student Financial Aid Matching / Level of Effort / Earmarking Eligibility

The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending accurate file submissions t...

The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending accurate file submissions to NSC in June 2024. Files generated and submitted under the College’s new processes are taking roughly one week to process from initial submission, through error correction, and finalization.

View Audit 366981

Finding 1154085 (2024-001)

Material Weakness 2024

Field to Market

DC

Allowable Costs / Cost Principles § 200.303 § 200.430

Management will update the entity’s accounting policies and procedures to include specific guidance on payroll allocation and documentation requirements for personnel expenses charged to Federal awards.

View Audit 366976

Finding 1153883 (2024-002)

Material Weakness 2024

Kentucky Health Department Association

KY

Questioned Costs Procurement, Suspension & Debarment § 200.317 § 200.326

Management’s Response: The Association will update its purchasing policy to ensure the procurement standards in 2 CFR 200.317 – 200.326 are incorporated.

View Audit 366950 Questioned Costs: $1

Finding 1153880 (2024-003)

Material Weakness 2024

Ho-Chunk Housing and Community Development Agency, Inc.

WI

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

Finding 2024-003 – Eligibility Assistance Listing No. 14.867 – Indian Housing Block Grant Condition: Pursuant to testing of eligibility and internal controls over eligibility, auditors noted the following control deficiency and noncompliance: • Seven tenants did not have an annual recertification or...

Finding 2024-003 – Eligibility Assistance Listing No. 14.867 – Indian Housing Block Grant Condition: Pursuant to testing of eligibility and internal controls over eligibility, auditors noted the following control deficiency and noncompliance: • Seven tenants did not have an annual recertification or inspection completed. Recommendation: We recommend that the Agency strengthen its internal controls over eligibility to monitor all relevant information and documentation affecting the eligibility process. Corrective Action Plan: 1. Implement Tracking System o Establish/Update the tracking log (electronic) to record due dates for all tenant annual recertifications and inspections. o Assign responsibility to a designated staff member for updating and monitoring the log monthly. 2. Supervisory Review o Require quarterly review of the tracking log to ensure all inspections and recertifications are current. 3. Corrective Action on Missing Inspections o Immediately complete any outstanding inspections and recertifications for the seven files. Name of Contact Person Responsible for Corrective Action Plan: Raven Rosin Anticipated Completion Date: November 1, 2025

View Audit 366937

Corrective Action Plans

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