Corrective Action Plans

Finding 1156773 (2024-003)

Material Weakness 2024

City of Atwater

MN

Procurement, Suspension & Debarment § 200.318

Procurement, Suspension and Debarment Program: Program: ALN 66.458 Clean Water State Revolving Fund ALN 66.468 Drinking Water State Revolving Fund Condition: The City’s procurement procedures do not conform to Uniform Guidance requirements. Corrective Action Planned: The City will update procurement...

Procurement, Suspension and Debarment Program: Program: ALN 66.458 Clean Water State Revolving Fund ALN 66.468 Drinking Water State Revolving Fund Condition: The City’s procurement procedures do not conform to Uniform Guidance requirements. Corrective Action Planned: The City will update procurement procedures to conform with Minnesota statutes and Uniform Guidance. Officer Responsible for Ensuring CAP: Goldie Smith, Clerk/Treasurer Planned Completion Date: 12/31/2025

View Audit 369103

Finding 1156771 (2024-006)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles

Emergency Solutions Grants Program – Assistance Listing No. 14. 231 Recommendation: We recommend that management ensure that internal controls are in place to ensure subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no dis...

Emergency Solutions Grants Program – Assistance Listing No. 14. 231 Recommendation: We recommend that management ensure that internal controls are in place to ensure subrecipient payments are paid timely and within program requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent recurrence, the following actions will be taken: - All future ESG contracts will be directly managed by the ESG Program Manager and Program Analyst, ensuring appropriate oversight and compliance with program requirements. - All program analysts will be retrained on invoice processing requirements. - The Program manager will evaluate the potential use of an online system for receiving and tracking invoices. Name(s) of the contact person(s) responsible for corrective action: Stephanie Green, Program Manager Planned completion date for corrective action plan: January 01, 2026

View Audit 369097

Finding 1156770 (2024-005)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

HUD Housing Programs Internal Control / Segregation of Duties

Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal...

Public and Indian Housing – Assistance Listing No. 14.850 Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent a recurrence of the issue, we have implemented a comprehensive corrective action plan. Staff developed a Quality Control Audit Checklist for Recertifications, written Standard Operating Procedures (SOP’s) for interviewing tenants; conducting income examinations and re-examinations; verifying income eligibility using third-party verification; and determining income eligibility and calculating the tenant’s rent payment. Additionally, SHRA recently held and certified our staff with Public Housing Specialist training through a certified vendor. We will continue to provide refresher trainings to assist staff with accurately determining program eligibility. Name(s) of the contact person(s) responsible for corrective action: Cecette Hawkins, Assistant Director Planned completion date for corrective action plan: December 31, 2025

View Audit 369097

Finding 1156769 (2024-004)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

HUD Housing Programs Special Tests & Provisions Significant Deficiency

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Agency review the controls in place to ensure that the inspections team can complete the re-inspections in a timely manner and are knowledgeable of all internal procedures in place over inspec...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that the Agency review the controls in place to ensure that the inspections team can complete the re-inspections in a timely manner and are knowledgeable of all internal procedures in place over inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reports have been implemented to track the scheduling and completion of inspections. These reports are reviewed regularly by the Owner Services Supervisor to ensure that all required inspections are completed on schedule. This tracking process strengthens internal controls and provides timely oversight, ensuring compliance with HUD’s inspection requirements. Name(s) of the contact person(s) responsible for corrective action: MaryLiz Paulson, Director, Housing Choice Vouchers Planned completion date for corrective action plan: December 31, 2025

View Audit 369097

Finding 1156766 (2024-003)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

Questioned Costs HUD Housing Programs Special Tests & Provisions

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Public Housing Authority (PHA) has designated the Owner Services Supervisor to oversee the inspection This role ensures that all inspections are completed in a timely and consistent manner. The supervisor is also responsible for verifying that Housing Assistance Payments (HAP) are only released for units that fully meet Housing Quality Standards (HQS) requirements. These measures strengthen oversight, improve accountability, and ensure compliance with federal regulations. Name(s) of the contact person(s) responsible for corrective action: MaryLiz Paulson, Director, Housing Choice Vouchers

View Audit 369097 Questioned Costs: $1

Finding 1156763 (2024-002)

Material Weakness 2024

Sacramento Housing and Revelopment Agency

CA

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that management should implement a quality control review over a sampling of tenant files recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordan...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend that management should implement a quality control review over a sampling of tenant files recertified each month. The purpose of the review is to determine if the tenant files were prepared in accordance with internal policies and verify the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We would like to provide additional context. The challenge is not due to a lack of monitoring efforts, but rather staffing constraints that have impacted our ability to meet recertification timelines. Specifically, the Agency is currently operating with an insufficient number of staff to manage the full caseload effectively. Additionally, a significant portion of the team responsible for processing recertifications consists of new hires who are still in training and not yet able to carry a full workload, which has temporarily reduced the overall output of the team. In response, we are actively working to streamline internal processes, prioritize core functions, and improve overall operational efficiency. These efforts are intended to increase the number of timely recertifications completed and ensure compliance with HUD requirements moving forward. Name(s) of the contact person(s) responsible for corrective action: MaryLiz Paulson, Director, Housing Choice Vouchers Planned completion date for corrective action plan:: December 31, 2025

View Audit 369097 Questioned Costs: $1

Finding 1156760 (2024-003)

Material Weakness 2024

Highland Health Providers

OH

Reporting

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Meghann Ackley, Chief Financial Officer

View Audit 369094

Finding 1156757 (2024-002)

Material Weakness 2024

Highland Health Providers

OH

Special Tests & Provisions

Planned Corrective Action: In 2024, the Health Center changed its sliding fee discount policy to be a flat rate discount rather than a percentage. The Health Center changed this policy to minimize future errors in the discount calculation. The 2 errors noted within the testing were for service dates...

Planned Corrective Action: In 2024, the Health Center changed its sliding fee discount policy to be a flat rate discount rather than a percentage. The Health Center changed this policy to minimize future errors in the discount calculation. The 2 errors noted within the testing were for service dates prior to the policy change. The Health Center believes that the issue should be resolved going forward. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Meghann Ackley, Chief Financial Officer

View Audit 369094

Finding 1156754 (2024-002)

Material Weakness 2024

Women's Foundation of Alabama

AL

Subrecipient Monitoring § 200.332

WFA Management’s Corrective Action Plan for Year Ended 12/31/2024 Finding number: 2024-002 Finding relates to subrecipient monitoring and management under 2 CFR Part 200. Corrective Action Plan The Women’s Foundation of Alabama is committed to ensuring clarity, accountability, and compliance in our ...

WFA Management’s Corrective Action Plan for Year Ended 12/31/2024 Finding number: 2024-002 Finding relates to subrecipient monitoring and management under 2 CFR Part 200. Corrective Action Plan The Women’s Foundation of Alabama is committed to ensuring clarity, accountability, and compliance in our grants management. To address the findings, we will: 􀁸 Implement the Subrecipient vs. Contractor Determination Form as a standard requirement for all agreements. For all agreements determined to be with subrecipients, a standardized agreement process to ensure that all required information is communicated and documented upfront. This includes clearly stating: o The federal award name and Assistance Listing Number (ALN). o A list of all applicable federal regulations. o Financial and performance reporting requirements and deadlines. Responsible Parties 􀁸 Chief Operating Officer – overall accountability for corrective action 􀁸 Director of Strategic Operations – coordination of implementation and recordkeeping 􀁸 Accounting Team (Mauldin & Jenkins): Technical assistance on compliance and reconciliation Anticipated Timeline 􀁸 Form and process adopted by [October 2025]

View Audit 369092

Finding 1156753 (2024-002)

Material Weakness 2024

Plumas-Sierra Rural Electric Cooperative

CA

Internal Control / Segregation of Duties Reporting Significant Deficiency

Management understands that the Cooperative must provide data for the proper periods when filing its quarterly reports. The Controller, Steve Malay, has implemented a review process to ensure that financial reports align with the periods specified in the grant agreements whenever possible. In instan...

Management understands that the Cooperative must provide data for the proper periods when filing its quarterly reports. The Controller, Steve Malay, has implemented a review process to ensure that financial reports align with the periods specified in the grant agreements whenever possible. In instances where complete information is not available within the required reporting window (due timing of information and required deadlines), management will provide the most reliable and available data at the time of reporting. This will be clearly documented to ensure transparency with granting agencies.

View Audit 369091

Finding 1156752 (2024-001)

Material Weakness 2024

Plumas-Sierra Rural Electric Cooperative

CA

Questioned Costs Allowable Costs / Cost Principles § 200.430

Management understands that CFR 200.430 requires compensation for personnel services to be based on records that accurately reflect the work performed, and costs must be properly allocated to benefiting programs or cost objectives. The HR/Payroll Administrator has implemented a review process to ens...

Management understands that CFR 200.430 requires compensation for personnel services to be based on records that accurately reflect the work performed, and costs must be properly allocated to benefiting programs or cost objectives. The HR/Payroll Administrator has implemented a review process to ensure that all payroll changes are properly reviewed, verified, and approved prior to final payroll processing and the Cooperative does not believe this should be in an issue going forward.

View Audit 369091 Questioned Costs: $1

Finding 1156737 (2024-003)

Material Weakness 2024

Oakland Livingston Human Service Agency

MI

Subrecipient Monitoring § 200.303

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task ...

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.

View Audit 369077

Finding 1156736 (2024-002)

Material Weakness 2024

Oakland Livingston Human Service Agency

MI

Subrecipient Monitoring § 200.303

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task ...

The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.

View Audit 369077

Finding 1156733 (2024-001)

Material Weakness 2024

Oakland Livingston Human Service Agency

MI

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.308 § 200.403

The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior ...

The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior to supervisor's approval of the cost.

View Audit 369077

Finding 1156730 (2024-006)

Material Weakness 2024

Roxboro Housing Authority

NC

HUD Housing Programs

2024-006 ALN 14.850 – Public Housing Operating Fund – Special Test – UEL Income Calculation Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion D...

2024-006 ALN 14.850 – Public Housing Operating Fund – Special Test – UEL Income Calculation Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025

View Audit 369076

Finding 1156729 (2024-005)

Material Weakness 2024

Roxboro Housing Authority

NC

HUD Housing Programs

2024-005 ALN 14.850 – Public Housing Operating Fund – Special Test – Public Housing Operating Funding Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director A...

2024-005 ALN 14.850 – Public Housing Operating Fund – Special Test – Public Housing Operating Funding Requirements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025

View Audit 369076

Finding 1156728 (2024-004)

Material Weakness 2024

Roxboro Housing Authority

NC

HUD Housing Programs

2024-004 ALN 14.850 – Public Housing Operating Fund – Special Test – Depository Agreements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Da...

2024-004 ALN 14.850 – Public Housing Operating Fund – Special Test – Depository Agreements Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025

View Audit 369076

Finding 1156727 (2024-003)

Material Weakness 2024

Roxboro Housing Authority

NC

HUD Housing Programs Subrecipient Monitoring Eligibility

2024-003 ALN 14.850 – Public Housing Operating Fund - Eligibility Current management acknowledges the finding and is following the auditor’s recommendations. Person Responsible for Correction of Finding: Froncello Bumpass, Interim Executive Director Anticipated Completion Date: December 31, 2025

View Audit 369076

Finding 1156726 (2024-003)

Material Weakness 2024

Amsterdam Housing Authority

NY

HUD Housing Programs Subrecipient Monitoring Allowable Costs / Cost Principles

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2024-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will establish internal tracking and reminder systems to ensure all required reports, including the final P&E and AMCC, are completed and submitted to HUD by the required due dates. Grant reporting responsibilities will be clearly assigned, and submission deadlines will be monitored by the Director of Finance to prevent future delays. These procedures will be implemented immediately. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.

View Audit 369074

Finding 1156725 (2024-004)

Material Weakness 2024

Amsterdam Housing Authority

NY

HUD Housing Programs Reporting

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...

Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (4) Finding 2024-004 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will strengthen procedures to ensure all interfund accounts are reconciled and settled monthly before completing the HUD-52681-B report. Accounting staff will review and verify key line items (including Unrestricted Net Position and Cash in Investments) against the general ledger prior to VMS submission. Supervisory review will be required to confirm accuracy. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.

View Audit 369074

Finding 1156722 (2024-001)

Material Weakness 2024

City of Platteville

WI

Internal Control / Segregation of Duties HUD Housing Programs

Finding #2024-001- Limited Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has co...

Finding #2024-001- Limited Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. All internal control duties can be classified into four broad categories: authorization, custody, recordkeeping, and reconciliation. No one person should have control of two or more of these four categories for any one cycle. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. Currently, there are the following overlapping duties: - Both Accounting Specialists have the authority to enter invoices into the system, print checks, and have access to the electronic signatures. Preferably, the check cutting process would separate the entering of payment information into the system and the ability to print signed checks. - One Accounting Specialist creates deposits and makes deposits with the bank. Although not the standard procedure, the Accounting Specialist has the authority to collect cash receipts. Ideally, separate individuals would collect cash and make deposits. - The Housing Authority Executive Director opens the mail, creates deposits and takes deposits to the bank. The Executive Director also enters invoices into the system and prints checks. The Board of Commissioners approves disbursements and all checks require dual signatures. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Cause: Limited number of personnel. Recommendation: We recommend that the City consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase personnel to bring about a more effective segregation of duties.

View Audit 369068

Finding 1156720 (2024-001)

Material Weakness 2024

Norton Healthcare, Inc. and Affiliates

KY

Allowable Costs / Cost Principles

Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially D...

Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Disaster Grants – Public Assistance of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Company does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the function’s review of unapproved timesheets. Planned corrective action: Norton Healthcare is currently upgrading its timekeeping and attendance system. As part of this initiative, enhanced training and expanded functionality for timekeepers will help ensure that timecards are reviewed and approved prior to payment, in compliance with internal requirements. Relevant policies and procedures will be updated to support this process, including the retention of appropriate documentation. Additionally, the Norton Clinical Agency will establish a formal written policy outlining the stipend review and approval process, ensuring that all documentation is properly maintained. All other expenses submitted to FEMA will be reviewed and approved in writing, outside of the Grants Portal, with appropriate documentation. At this time, there are no pending or anticipated projects related to FEMA claims. Anticipated completion date: December 31, 2026 Responsible contact person: Adam Kempf

View Audit 369066

Finding 1156719 (2024-005)

Material Weakness 2024

Advocate Aurora Health, Inc.

IL

Equipment & Real Property Management

Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are ...

Finding 2024-005 National Bioterrorism Hospital Preparedness Program (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2), and to ensure that physical inventory procedures are conducted over property at least once every two years as it pertains to the Program. Management Response: To address this deficiency, the Program and Fixed Asset Accounting teams will collaborate to ensure adherence to the established asset tracking and inventory management procedures. This joint effort will ensure that the subsidiary ledger is accurately maintained, equipment acquired through federal grants is properly recorded, and physical inventories are conducted within the prescribed biennial timelines in compliance with 2 CFR section 200.313(d). Contact Person (s) Responsible for Corrective Action: Steve Baron, Program Manager and Tony Hamric, Fixed Assets Manager. Anticipated Completion Date: December 31, 2025

View Audit 369065

Finding 1156714 (2024-003)

Material Weakness 2024

Advocate Aurora Health, Inc.

IL

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

Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were ...

Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.

View Audit 369065

Finding 1156705 (2024-004)

Material Weakness 2024

Advocate Aurora Health, Inc.

IL

Eligibility Matching / Level of Effort / Earmarking

Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibil...

Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibility will be developed. This procedure will include detailed steps and required documentation, supported by a standardized eligibility checklist to guide staff in confirming and accurately recording participant eligibility. Additionally, all program staff involved in intake and eligibility determination will be trained on the new procedure. Contact Person - Responsible for Corrective Action: Elizabeth LaRoy, Program Manager Anticipated Completion Date: December 31, 2025.

View Audit 369065

Corrective Action Plans

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