Corrective Action Plans

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Finding 570576 (2025-001)
Significant Deficiency 2025
Finding 2025-001: Comments on the Finding and Each Recommendation: During the year ended March 31, 2025, the Corporation withdrew $6,905 from the reserve for replacements without a HUD approved 9250.The Corporation should transfer $6,905 from operating cash into the reserve for replacements. Action...
Finding 2025-001: Comments on the Finding and Each Recommendation: During the year ended March 31, 2025, the Corporation withdrew $6,905 from the reserve for replacements without a HUD approved 9250.The Corporation should transfer $6,905 from operating cash into the reserve for replacements. Action(s) taken or planned on the finding Management concurs with the recommendation. On April 26, 2024, the Corporation transferred $6,905 from the operating cash account to the reserve for replacement account.
View Audit 361606 Questioned Costs: $1
Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new p...
Management concurs with the findings and had already commenced corrective actions prior to the issuance of this report. These actions were initiated to address deficiencies resulting from the inadequate performance of the former property manager, who resigned from the position. Additionally, a new property manager has been hired to ensure compliance with established procedures and to oversee the continued implementation of corrective measures.
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
View Audit 359677 Questioned Costs: $1
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This w...
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications o...
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and Correction Upon determination of the finding, we conducted a full review of the affected patient account. 2. Staff Training All Outreach and Eligibility staff have received refresher training on the proper application of the sl iding fee scale, including income verification processes and documentation standards. This training now occurs as part of onboarding and annually thereafter. 3. Policy and Procedure Review We reviewed our internal policies and procedures to ensure clear guidance on income documentation requirements, allowable income sources, and how to properly apply the sliding scale. 4. Double-Verification Process A second-level review has been instituted for all new patient applications and renewals involving sliding fee scale determinations. This ensures that income is correctly assessed, and the appropriate fee level is applied before any charges are finalized. 5. Audit and Monitoring A quarterly internal audit process has been implemented to review a random sample of sliding fee scale determinations for accuracy. Findings from these audits will be tracked, and any trends will be addressed through targeted training or process changes. Ongoing Commitment: We are committed to continuous improvement and will monitor the effectiveness of these corrective actions over the next year. Adjustments will be made as necessary to ensure sustained compliance and fairness in our billing practices. Our goal is to uphold transparency and affordability in patient care while maintaining full adherence to regulatory standards. Contact Person: Tamie Olson, Chief Financial Officer Completion Date: Fiscal year ending January 31, 2026
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nan...
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan C...
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure ...
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure that all resident files are maintained at the site for each resident of the Property in accordance with the HUD Handbook 4350.3. Management Response: Management agrees with the recommendation and will ensure that resident files are retained in accordance with the HUD Handbook 4350.3. The resident moved-out on June 13, 2024. No further action is required.
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying th...
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying the invoices approved by HUD and had not paid as of January 31, 2025. Recommendation: Management should ensure that HUD approved reserve for replacement withdrawals are used for the approved purposes. Management Response: Agree. The Corporation paid the remaining costs included in the HUD approved withdrawal on March 3, 2025. There is no further action required.
View Audit 355850 Questioned Costs: $1
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within...
Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within the accounting and finance department are able to complete their tasks in a more timely manner.
Assistance Listing 14.231 Emergency Solutions Grants Program Assistance Listing 93.224 & 93.527 Health Center Program & Grants for New and Expanded Services under the Health Center Program Assistance Listing 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Publi...
Assistance Listing 14.231 Emergency Solutions Grants Program Assistance Listing 93.224 & 93.527 Health Center Program & Grants for New and Expanded Services under the Health Center Program Assistance Listing 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Assistance Listing 93.667 Social Services Block Grant Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: Although we acknowledge that certain prior-year expenditures were recorded in the FY24 SEFA, we do not believe these errors were material to the basic financial statements. In addition, we do not believe that including these expenditures affected the determination of major programs or our compliance with any federal grant requirements. We confirm that our financial statements are prepared in accordance with Generally Accepted Accounting Principles and that, as presented, they are materially accurate. For FY 2025, we expanded our search for unrecorded liabilities to include activity through seven months after year-end. Because the risk of unrecorded liabilities declines as we move further from fiscal year-end, we focused our review on transactions that could reasonably have a material impact on the financial statements. We will work closely with all departments to ensure that any outstanding obligations that have not yet been vouchered are identified and addressed. Contact Person: Shantae Thorpe, Accounting Manager, Finance, 215-686-5629
Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: HHS acknowledges the Controller’s finding that management decision letters were not issued for specific subrecipient audit findings under ALN 93.914, as required under 2 CFR 2...
Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: HHS acknowledges the Controller’s finding that management decision letters were not issued for specific subrecipient audit findings under ALN 93.914, as required under 2 CFR 200.332(e) and 200.521. While the formal letters were not issued, HHS did review the audit findings, obtained and evaluated the subrecipients’ corrective action plans and confirmed that no questioned costs or additional risks remained. These steps ensured that the underlying corrective actions were completed. To strengthen documentation and ensure consistency across all federal programs, HHS will adopt the following corrective measures: 1.Standard management Decision Template •HHS will adopt a simple, uniform management decision template and clear steps for documenting decisions within the required federal timelines. 2.Central Location for Documentation •HHS will store all management decision letters and related materials in one designated shared location to ensure accessibility and consistent record-keeping. 3.Brief Staff Guidance •HHS will provide concise written guidance to staff outlining: oWhen a management decision is required, oHow to complete it using the template, and oWhat documentation must be retained? These corrective actions will ensure consistent compliance with federal requirements while supporting the City’s long-term goal of standardizing financial processes across departments. Contact Person: Landuleni Shipanga, Controller, City of Philadelphia Office of Children and Families, 215-683-6366
Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the Office of the City Controller’s finding. PDPH maintains a process to iden...
Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the Office of the City Controller’s finding. PDPH maintains a process to identify subrecipients during the contracting process. Contracts with subrecipients include federal compliance language. The three entities identified in this finding, including Concilio, Urban Affairs Coalition (UAC), and Public Health Management Corporation (PHMC), should have been classified as vendors and not subrecipients. These entities were not responsible for programmatic decision-making. This error has been corrected in subsequent contracts. Despite the misclassification, appropriate vendor monitoring was conducted, including supervision of staff hiring and monitoring and reconciliation of monthly invoice packages. Contact Person: Jessica Caum, Director, Department of Public Health, 215-685-6731 Naomi Mirowitz, Performance and Compliance Officer, Department of Public Health, 215-964-5050
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the findings of the Office of the City Controllers. PDPH confirms that r...
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the findings of the Office of the City Controllers. PDPH confirms that risk assessments and related monitoring documentation for all subrecipients were not consistently completed or retained during the audit period, primarily due to staff turnover and limited administrative capacity within the grants management function. To address this, the Division of Substance Use Prevention and Harm Reduction (SUPHR) has initiated corrective measures to strengthen compliance with the requirements of 2 CFR 200.332. These measures include implementation of standardized tools and procedures to ensure that subrecipient risk assessments, monitoring activities, and the review of financial and performance reports are conducted in a consistent, timely, and well-documented manner. Implementation of these improvements will enhance internal controls, ensure appropriate oversight of subrecipients, and promote full compliance with federal regulations. The Department anticipates that tools and standard operating procedures will be finalized by December 19, 2025, with full implementation of corrective actions by March 3, 2026. Contact Person: Daniel Teixeira da Silva, Director, Division of Substance Use Prevention and Harm Reduction (SUPHR), 267-760-0307
Assistance Listing 97.083 Staffing for Adequate Fire and Emergency Views of the Responsible Officials and Corrective Action Plan: This finding pertains to a single Federal Financial Report (FFR) for period ending June 30th, 2024. This was the first and only FFR for this grant that the Philadelphia F...
Assistance Listing 97.083 Staffing for Adequate Fire and Emergency Views of the Responsible Officials and Corrective Action Plan: This finding pertains to a single Federal Financial Report (FFR) for period ending June 30th, 2024. This was the first and only FFR for this grant that the Philadelphia Fire Department prepared independently. The report was subsequently reviewed, approved, and accepted by FEMA. All subsequent and future FFRs have been submitted through the FEMA GO portal, where FEMA pre-populates the digital worksheet with the relevant figures. It should be noted that these pre-populated amounts align with PFD reimbursement requests for each reporting period, rather than the city’s total expenditures on salaries and benefits during the same period. Upon notification of the discrepancy by the Controller’s office, PFD promptly contacted both FEMA and the City’s Grants office to seek clarification and guidance. Due to the federal government shutdown, FEMA has not yet responded. PFD will re-engage FEMA once normal operations resume, and if warranted will submit a revised FFR. PFD emphasizes that the discrepancy identified on the single FFR does not impact the available grant funding. Contact Person: Kelly Collins, Deputy Commissioner, Fire, 215-906-8976
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and...
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and Corrective Action Plan: ALN 93.136 – Injury Prevention and Control Research and State/Community Based Programs PDPH acknowledges that Federal Funding Accountability and Transparency Act (FFATA) reporting requirements were not consistently met during the audit period due to limited staff capacity and lack of clearly defined procedures for subaward reporting. In response, SUPHR will establish procedures to ensure timely and accurate FFATA reporting in accordance with federal requirements. These procedures include designating responsible staff, assigning appropriate SAM.gov access roles, and providing orientation and training on subaward reporting processes. Standardized documentation and retention practices will also be implemented to ensure proper recordkeeping and verification of all submissions. SUPHR is committed to maintaining compliance with FFATA requirements going forward and will continue to monitor adherence through routine oversight by the grants management team. Initial implementation of corrective measures will begin upon receipt of an approved Year 3 budget from the Centers of Disease Control. ALN 93.323 – Epidemiology and Lab Capacity Program PDPH acknowledges the error that occurred with FFATA reporting with respect to its incomplete reporting. This grant had previously been connected in the FSRS.gov system to a PDPH division that was created during the COVID pandemic that no longer exists. Although the grant was listed under the Division of Disease Control by FY24, the FFATA was overlooked and not completed. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. ALN 93.354 – Public Health Emergency Response PDPH acknowledges that errors occurred with FFATA reporting with respect to both the timing of the reporting and the amounts of subawards reported. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. Contact Persons: Daniel Teixeira da Silva, Director, Division of Substance Use Prevention and Harm Reduction (SUPHR), 267-760-0307 Jessica Caum, Public Health Preparedness Program Manager, Philadelphia Department of Public Health, 215-685-6731
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potenti...
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potential contract concern involving the Resources for Human Development. In accordance with established financial oversight protocols, the Finance Department placed a temporary hold on related payments pending further review. Once the review was concluded, the payments were released. Additionally, limitations within the FAMIS system, specifically its inability to retain original voucher creation dates after rejection and resubmission, contributed to the appearance of delayed liquidation. To prevent recurrence, the Office of Homeless Services will strengthen its closeout procedures to ensure timely review and liquidation of all obligations in accordance with 2 CFR § 200.344. The Office will also initiate earlier coordination with the Finance Department when payment holds arise and reinforce staff training on grant closeout and escalation protocols. These corrective actions will enhance compliance and reduce the likelihood of future delays. Contact Person: Jerome Hill, Director of Compliance, OHS, 215-686-0371
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delays in processing invoices were due to heightened fiscal oversight implemented after it was determined that the...
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delays in processing invoices were due to heightened fiscal oversight implemented after it was determined that the Office had exceeded its budget allocation. As a result, all invoices for OHS-contracted services were subject to additional layers of review beyond the standard OHS and Finance approval process. These invoices were routed to the Managing Director’s Office before payment authorization, which extended the normal processing timelines. To prevent recurrence, the Office of Homeless Services will strengthen its invoice-processing policies and procedures to ensure timely review and payment of all subrecipient invoices, consistent with applicable federal requirements. Now that the enhanced review protocols are no longer in effect, OHS will reestablish standard review timelines and reinforce internal expectations for prompt processing. OHS will also provide guidance to fiscal staff on escalation procedures should future budgetary reviews impact invoice timeliness. These corrective actions will support improved compliance and reduce the likelihood of processing delays. Contact Person: Jerome Hill, Director of Compliance, OHS, 215-686-0371
Views of Responsible Officials and Planned Corrective Actions The Grants Administrator and the Finance Department is working closely to compare all expenditures incurred by quarter to the expenditures as reported to the grantor in the quarterly reports. The Grants Administrator and Finance Departmen...
Views of Responsible Officials and Planned Corrective Actions The Grants Administrator and the Finance Department is working closely to compare all expenditures incurred by quarter to the expenditures as reported to the grantor in the quarterly reports. The Grants Administrator and Finance Department have been working to make any corrections necessary for reporting purposes and to address the timing and presentation issues of expenditures as incurred versus as reported. Going forward, the Grants Administrator will be more involved in communicating with the Finance Department, at a minimum on a monthly basis, in regard to the reporting of expenditures that are being funded by federal, state, and local awards.
2024-001 The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Assistance Listing Number and Title: 93.354 COVID 19 - Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Fe...
2024-001 The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Assistance Listing Number and Title: 93.354 COVID 19 - Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Federal Grantor Name: Department of Centers for Disease Control and Prevention, Health and Human Services Federal Award/Contract Number: N/A Pass-through Entity Name: Washington State Department of Health Pass-through Award/Contract Number: CLH31004 Known Questioned Cost Amount: $0 Prior Year Audit Finding: N/A Background During fiscal year 2024, the District spent $321,653 in Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response program funds. The intent of this program is to fund state, local and territorial public health departments for public health emergencies having an overwhelming impact on jurisdictional resources. These emergencies require federal support to effectively respond to, manage and address a significant public health threat. In addition to immediate response activities, this program provides a mechanism to accelerate readiness for an impending infectious disease threat or other public health crises identified on the event horizon. Federal regulations require recipients to establish, document and maintain effective internal controls that ensure compliance with program requirements. These controls include understanding program requirements and monitoring the effectiveness of established controls. Federal requirements prohibit recipients from contracting with or purchasing from parties suspended or debarred from doing business with the federal government. Whenever the District enters into contracts or purchases goods and services that it expects to equal or exceed $25,000, paid all or in part with federal funds, it must verify the contractors are not suspended, debarred or otherwise excluded from participating in federal programs. The District may verify this by obtaining a written certification from the contractor, adding a clause or condition into the contract that states the contractor is not suspended or debarred, or checking for exclusion records in the U.S. General Services Administration’s System for Award Management at SAM.gov. The District must verify this before entering into the contract, and must maintain documentation demonstrating compliance with this federal requirement. Description of Condition Although the District has a process to verify the suspension and debarment status for contractors it pays more than $25,000, our audit found the District did not follow this process and did not verify all contractors were not suspended or debarred before purchasing from them. We consider this deficiency in internal controls to be a material weakness that led to material noncompliance. Cause of Condition Although District staff were aware of the requirements, they could not locate documentation to show they verified the contractor’s suspension and debarment status before entering into the contract or purchasing from them. Effect of Condition The District did not obtain a written certification from the contractors, insert a clause into the contracts or check for exclusion records at SAM.gov to verify contractors it paid $74,738 using federal funds were not suspended or debarred before contracting. Without adequate internal controls, the District increases its risk of awarding federal funds to contractors that are excluded from participating in federal programs. Any payments the District made to an ineligible party would be unallowable, and the awarding agency could potentially recover them. We subsequently verified the contractors were not suspended or debarred. Therefore, we are not questioning costs. Recommendation We recommend the District strengthen its internal controls to verify all contractors it pays $25,000 or more, all or in part with federal funds, are not suspended or debarred from participating in federal programs and maintain documentation demonstrating compliance with this requirement. District’s Response The Health District concurs with the finding. While the issue was limited to documentation of verification timing, we recognize the importance of maintaining clear evidence that suspension and debarment checks are completed prior to entering into contracts or issuing payments under federally funded programs. To strengthen our internal controls and ensure full compliance with federal requirements, the District has developed and initiated the following corrective actions, consistent with our attached Corrective Action Plan: 1. Formal Verification Procedure: A new written procedure now requires verification of all contractors receiving $25,000 or more in federal funds through the System for Award Management (SAM.gov) prior to contract execution or payment. 2. Contractor Attestations: Contracts will include clauses affirming that vendors are not suspended or debarred, and contractors must provide written certification confirming compliance. 3. Documentation Retention: Verification evidence—including dated SAM.gov screenshots or printed reports—will be maintained in each contractor’s procurement file. 4. Staff Training: Fiscal and procurement personnel have received updated training to reinforce understanding of suspension and debarment requirements and the new verification process. 5. Internal Review: Supervisory review procedures have been updated to confirm verification and documentation completion before disbursement of federal funds. The District anticipates completing full implementation of these corrective measures by November 07, 2025. Auditor’s Remarks We appreciate the District’s commitment to resolving the issues noted and will follow up during the next audit. Applicable Laws and Regulations Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), section 516, Audit findings, establishes reporting requirements for audit findings. Title 2 CFR Part 200, Uniform Guidance, section 303 Internal controls, describes the requirements for auditees to maintain internal controls over federal programs and comply with federal program requirements. The American Institute of Certified Public Accountants defines significant deficiencies and material weaknesses in its Codification of Statements on Auditing Standards, section 935, Compliance Audits, paragraph 11. Title 2 CFR Part 180, OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement), establishes nonprocurement debarment and suspension regulations implementing Executive Orders 12549 and 12689.
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