Corrective Action Plans

Finding 574144 (2024-004)

Significant Deficiency 2024

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.328 § 200.329

Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.

View Audit 364712

Finding 574143 (2024-003)

Significant Deficiency 2024

Christmas Valley Domestic Supply District

OR

Procurement, Suspension & Debarment § 200.318 § 200.326

District has been in discussion with our attorney and have already got a new ordinance written and put into effect as of June 1, 2025. CVDWSD currently has a procurement policy as a ordinance.

View Audit 364712

Finding 574141 (2024-002)

Significant Deficiency 2024

Aurora/arapahoe Battered Women's Shelter, Inc. Dba Gateway Domestic Vi

CO

Allowable Costs / Cost Principles § 200.303 § 200.430

Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online so...

Gateway Domestic Violence Services, in 2024, was utilizing paper timesheets that included the funder allocation for each staff person. The funder allocations were then entered into QuickBooks spreadsheets. In February of 2025, we engaged with Paychex Payroll Services which utilizes simple online software built to streamline payroll and automate taxes. It does include a job costing process that allows for identifying payroll costs to be distributed appropriately to funders. This electronic payroll system decreases the chances of human error. Also in August of 2025, there is a change in personnel to Finance & Operations Director rather than Finance and Operations Manager. The new position comes with increased responsibilities and increased skills. This position will be responsible for reconciling payroll allocations from Paychex to Payroll allocations in QuickBooks to government funding reports to ensure accuracy. These changes along with the systems that we have had in place should help prevent this issue from being repeated.

View Audit 364709

Finding 574140 (2024-002)

Significant Deficiency 2024

Town of Babylon

NY

Reporting Internal Control / Segregation of Duties § 200.328

The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mi...

The Town acknowledges the finding related to the delayed submission of the 4th Quarter 2024 ARPA report and concurs with the auditor’s recommendation. While the Town ultimately recognizes its responsibility to meet the filing deadlines for all federal reporting, the Town has instituted efforts to mitigate the reporting lapse since the oversight. To prevent recurrence, the Town has implemented the following corrective actions: 1. Formal Reporting Calendar: A centralized ARPA reporting calendar has been created. This calendar will include internal deadlines at least 14 days in advance of federally mandated submission dates. 2. Assigned Reporting Officer: A designated ARPA Reporting Officer has been appointed, responsible for coordinating all necessary documentation and submissions related to ARPA funding. 3. Pre-Submission Review Process: A new protocol has been established requiring internal review and sign-off from both the Comptroller and the Town Supervisor’s designee no less than one week prior to each deadline. 4. Ongoing Training and Coordination: The Town will continue to work closely with its auditors and legal counsel to remain current on federal guidance, ensure continued compliance with Uniform Guidance standards, and maintain internal staff awareness of applicable obligations under ARPA. We believe these measures will ensure timely and accurate reporting for all future quarters and strengthen our internal compliance infrastructure.

View Audit 364708

Finding 574139 (2024-001)

Significant Deficiency 2024

Town of Babylon

NY

Reporting § 200.328

The grant administrator shall include notifications within their Outlook calendar two weeks prior to the due date for each progress report deadline. This will ensure progress reportes are completed and submitted on time.

View Audit 364708

Finding 574132 (2024-005)

Significant Deficiency 2024

Legacy Medical Care Inc.

IL

Procurement, Suspension & Debarment § 200.212 § 200.318

Action taken in response to finding: • LMC Staff will be re-trained on the process and importance of retaining documentation that SAM.gov was used to verify that a vendor was not suspended, debarred or otherwise excluded from participating in the transaction prior to contract. • LMC staff will revie...

Action taken in response to finding: • LMC Staff will be re-trained on the process and importance of retaining documentation that SAM.gov was used to verify that a vendor was not suspended, debarred or otherwise excluded from participating in the transaction prior to contract. • LMC staff will review the OIG exclusions list prior to onboarding or signing contracts with vendors. • LMC staff will print and retain proof of each review for reporting purposes Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

View Audit 364705

Finding 574131 (2024-004)

Material Weakness 2024

Legacy Medical Care Inc.

IL

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

View Audit 364705

Finding 574130 (2024-003)

Material Weakness 2024

Legacy Medical Care Inc.

IL

Procurement, Suspension & Debarment § 200.320

Action taken in response to finding: •LMC staff will receive further training in the use of sole source documentation, and the established policies and procedures for purchasing and procurement. •LMC staff responsible for purchasing and agreements will follow the established policy and procedures fo...

Action taken in response to finding: •LMC staff will receive further training in the use of sole source documentation, and the established policies and procedures for purchasing and procurement. •LMC staff responsible for purchasing and agreements will follow the established policy and procedures for procurement. •LMC staff will develop and maintain tracking mechanisms related to the methodology used for each noncompetitive procurement. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

View Audit 364705

Finding 574129 (2024-002)

Material Weakness 2024

Legacy Medical Care Inc.

IL

Material Weakness Internal Control / Segregation of Duties

Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible fo...

Action taken in response to finding: •LMC will increase the frequency and sample size of its review of patient encounters. •LMC will be providing additional training for front desk staff regarding the collection and verification of patient information. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 08/15/2025

View Audit 364705

Finding 574123 (2024-001)

Significant Deficiency 2024

Response of Suffolk County, Inc.

NY

Allowable Costs / Cost Principles § 200.430

2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN...

2024-001. Allowable Costs/Cost Principles United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Passed Through Vibrant Emotional Health: Substance Abuse and Mental Health Services Administration - 988 National Suicide Prevention Lifeline ALN: 93.243 Substance Abuse and Mental Health Services Administration - Disaster Distress Helpline ALN: 93.243 Passed Through New York State Office of Mental Health: Substance Abuse and Mental Health Services Administration - 988 S11MY1 ALN: 93.243 Condition: Time records prepared by employees reflect the total hours worked for the day, but do not reflect the actual time spent on programs funded by each federal award, rather they are based on budgeted hours. Recommendation: The Organization’s use of Personnel Activity Report (PAR) equivalent documentation should allow each employee to accurately reflect the time work is performed for each federal award. Corrective Action: The Organization will complete the implementation of procedures for its time keeping records, which will provide information for PAR equivalent documentation. Actual time worked performing duties funded by each federal award will be reflected. Responsible Contact Person(s): Meryl Cassidy, Executive Director Response of Suffolk County, Inc., - P.O. Box 300 - Stony Brook, New York 11790 Anticipated Completion Date: December 31, 2025.

View Audit 364704

Finding 574121 (2024-001)

Material Weakness 2024

Wessington Springs School District No. 36-2

SD

Internal Control / Segregation of Duties Material Weakness

For this finding, Dr. Michael Ormsmith is the contact person responsible for the corrective action plan. This finding is due to having only two employees in the Business Office, both who have separate duties to cover the workload. Staffing in the office is at an efficient and financially feasible ...

For this finding, Dr. Michael Ormsmith is the contact person responsible for the corrective action plan. This finding is due to having only two employees in the Business Office, both who have separate duties to cover the workload. Staffing in the office is at an efficient and financially feasible level and precludes the hiring of additional personnel to provide an ideal environment for internal controls. The Wessinton Springs School Districted adopted Policy DA-R(1) Fiscal Management Internal Controls and Procedures on January 9, 2023. The district is aware of the weakness in internal controls and will adhere to the policy we have in place while providing compensating controls to reduce the risk. This is an ongoing process.

View Audit 364703

Finding 574119 (2024-001)

Significant Deficiency 2024

Brockton Housing Authority

MA

Questioned Costs HUD Housing Programs Eligibility

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff ...

The Brockton Housing Authority {The Authority) has reviewed and agrees with finding 2024-01. The Authority has experienced a large turnover in staff who are responsible for the calculations of rents and Housing Assistance Payments. Through promotions, retirements, and resignations 7 of the 10 staff primarily responsible for this function have left their positions in the last two years and have been replaced by staff new to the position. The Authority did increase quality control reviews due to the transition period. The finding does not identify a systemic issue rather it found various instances of noncompliance. Prior to the Audit the Authority scheduled a three-day onsite rent calculation training for all staff with Nan McKay inc that occurred the week of May 20, 2025. Finding 2024-001- Moving To Work Demonstration Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance and Significant Deficiency Corrective Action Plan: The Authority will continue and enhance its training regimen for staff responsible for rent determination. Furthermore, the Authority has engaged the services of Edgemere Consulting. As part of this engagement Edgemere will conduct an independent quality control review of public housing and rental assistance files. From the information gathered from the file review Edgemere Consulting will develop specific training initiatives for the staff including enhanced quality control measures. Person Responsible: Bruna Campbell, Compliance officer Anticipated Completion Date: December 31, 2025 - Ongoing

View Audit 364699 Questioned Costs: $1

Finding 574118 (2024-003)

Material Weakness 2024

Paint Valley Local School District

OH

Subrecipient Monitoring Period of Performance Reporting § 200.328 § 200.344 § 200.502

Management will ensure Federal expenditures are obligated during proper period and reported appropriately.

View Audit 364686

Finding 574117 (2024-002)

Material Weakness 2024

Paint Valley Local School District

OH

Internal Control / Segregation of Duties

Management will ensure District maintains all documentation to meet wage rate requirements of Federal programs.

View Audit 364686

Finding 574107 (2024-001)

Significant Deficiency 2024

Town of Ramah, Colorado

CO

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

The Town of Ramah is in the process of creating a Procurement Policy.

View Audit 364684

Finding 574104 (2024-001)

Significant Deficiency 2024

Search for Common Ground

DC

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.328

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took so...

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available

View Audit 364670

Finding 574102 (2024-002)

Significant Deficiency 2024

Search for Common Ground

DC

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.303

Due to lack of submission date field in Sam.gov system, we agree that we will add an alternate process to document timely submission for subawards reports on Sam.gov. This will be done by downloading the PDF report and confirming through email from Senior compliance officer.

View Audit 364670

Finding 574100 (2024-003)

Significant Deficiency 2024

Search for Common Ground

DC

Procurement, Suspension & Debarment

We have conducted trainings of our staff and rolled out Global procurement system during 2024 and it has resulted in higher compliance in procurement and specifically vendor screenings. Current instances are coming from the period before rolling out of Global procurement system. we will make sure we...

We have conducted trainings of our staff and rolled out Global procurement system during 2024 and it has resulted in higher compliance in procurement and specifically vendor screenings. Current instances are coming from the period before rolling out of Global procurement system. we will make sure we update vetting process for vendors coming from before rolling out of Global Procurement System.

View Audit 364670

Finding 574090 (2024-010)

Significant Deficiency 2024

Commonwealth of Puerto Rico Department of Labor and Human Resources

PR

See Corrective Action Plan table/chart.

View Audit 364669

Finding 574089 (2024-009)

Material Weakness 2024

Commonwealth of Puerto Rico Department of Labor and Human Resources

PR

See Corrective Action Plan table/chart.