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Corrective Action Plans

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Finding 573892 (2024-002)
Material Weakness 2024
Aids Council of Northeastern New York, Inc. D/b/a Alliance for Positive Health
NY
Allowable Costs / Cost Principles § 200.414
Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is s...
Starting in May 2024, the Alliance adapted its monthly Time and Effort Report that is reviewed by Kim Atkins, Executive Director, to be used for allocation of expenses other than payroll. This ensures a consistent, reviewed and authorized report is being used for expense allocation. This report is shared monthly with the Alliance’s funding agencies along with the submission of monthly vouchers for processing. During the year ended June 30, 2025, the Alliance has ensured that allocations were signed off on by Kim and has significantly reduced the amount of finance staff time required to process the allocation of administrative costs. As of July 1, 2025, the approved staff allocations are being uploaded into ADP in the anticipation of a direct link between ADP and the NetSuite general ledger so that personnel costs will be allocated automatically going forward. As of July 1, 2025 the Alliance is modifying all of its grants to adopt the 15% de minimis cost rate for all expenses other than personnel, direct program, and space costs.
View Audit 364554
Finding 573887 (2024-002)
Material Weakness 2024
Minneapolis American Indian Center
MN
Reporting § 200.510
Recommendation: After thoroughly reviewing the unique circumstance that led to this audit finding, we have determined that it is highly unlikely to recur. Given the organization's strong compliance history and familiarity with SEFA reporting under Uniform Guidance, we do not see a cost-effective ben...
Recommendation: After thoroughly reviewing the unique circumstance that led to this audit finding, we have determined that it is highly unlikely to recur. Given the organization's strong compliance history and familiarity with SEFA reporting under Uniform Guidance, we do not see a cost-effective benefit to revamping internal controls specifically for the issue. Instead, we recommend continuing to: review government awards, provide refresher trainings to staff, and conduct periodic reviews of internal controls to ensure ongoing compliance. These measures will effectively address the finding without incurring unnecessary costs. Planned Action: The organization acknowledges this was a unique situation and it is unlikely to recur. As a precaution, we will be reviewing training with staff and conduct periodic and annual reviews of the SEFA related funds. We will also continue to bring unique situations to the attention f the auditors to maintain our strong compliance history.
View Audit 364547
Finding 573884 (2024-007)
Significant Deficiency 2024
Northern Lakes Community Mental Health
MI
Cash Management Significant Deficiency
Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective...
Finding 2024-007 – Cash Management: Type: Significant Deficiency in Internal Control. Condition: The CMHSP did file FSRs for reimbursement. However, during testing it was noted that expenses listed in 1 of the 4 monthly FSRs tested were not supported by the books and records of the CMHSP. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that expenses listed in reports are supported by our books and records. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530
Finding 573883 (2024-006)
Significant Deficiency 2024
Northern Lakes Community Mental Health
MI
Subrecipient Monitoring Cash Management Reporting § 200.303
Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and a...
Finding 2024-006 – Cash Management (repeat comment): Type: Significant Deficiency in Internal Control. Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing, we noted that cash requests did not contain evidence of required review and approvals. Corrective Action: Current Finance staff will review our internal controls and make changes to ensure that cash requests are reviewed and approved prior to submission. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530
Finding 573882 (2024-005)
Material Weakness 2024
Northern Lakes Community Mental Health
MI
Reporting Subrecipient Monitoring Cash Management § 200.328
Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes...
Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530
Finding 573881 (2024-004)
Material Weakness 2024
Northern Lakes Community Mental Health
MI
Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.320
Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that...
Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that the vendors were not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Corrective Action: Current Finance staff will ensure that procurement measures are followed and that vendors are not suspended or debarred or disqualified. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024
View Audit 364530 Questioned Costs: $1
Finding 573874 (2024-002)
Significant Deficiency 2024
Transit Authority of Northern Kentucky
KY
Procurement, Suspension & Debarment § 200.318
Finding 2024-002: Federal Transit Cluster – Procurement and Suspension and Debarment (Noncompliance and Significant Deficiency in Internal Control) Condition: In some procurement files, TANK had missing documentation of procurement history, missing required contract clauses, lack of evidence of cont...
Finding 2024-002: Federal Transit Cluster – Procurement and Suspension and Debarment (Noncompliance and Significant Deficiency in Internal Control) Condition: In some procurement files, TANK had missing documentation of procurement history, missing required contract clauses, lack of evidence of contractor responsibility determination and missing lobbying and Buy America certifications. Corrective Action: TANK implemented new procurement procedures and a revised checklist which outline and confirm all of the FTA-required clauses for any federal procurement. TANK documented and submitted procedures for obtaining signed lobbying and Buy America certifications in all procurements over $100,000/$150,000. TANK documented our procurement procedure which requires a responsibility determination to verify that contractors were not debarred or suspended from participating in federal awards by checking for System Award Management (SAM) certification. TANK included in the new procurement procedures an update of the record-keeping of procurement history to include elements such as rationale for the method of procurement; selection of contract type; reason for contractor selection or rejection; and basis for the contract price. Responsible Party: Lyndi Whiteker, Procurement Analyst Anticipated Completion Date: Complete and findings were closed between 7/19/2024-11/26/2024.
View Audit 364521
Finding 573867 (2024-001)
Significant Deficiency 2024
Transit Authority of Northern Kentucky
KY
Questioned Costs Cash Management § 200.305
Finding 2024-001: Federal Transit Cluster – Cash Management/Financial Management and Capacity (Noncompliance and Significant Deficiency in Internal Control) Condition: TANK staff drew down federal funds in advance of allowable expenditures and did not disburse the federal funds within the required t...
Finding 2024-001: Federal Transit Cluster – Cash Management/Financial Management and Capacity (Noncompliance and Significant Deficiency in Internal Control) Condition: TANK staff drew down federal funds in advance of allowable expenditures and did not disburse the federal funds within the required three business days. Corrective Action: TANK has worked with the FTA to address this finding. We have developed procedures for: adherence to federal regulations related to federal grants management, training of all staff involved in the management of federal grants, and identifying back-ups who are trained/educated on doing this work. The procedures include explicit instruction on federal drawdown procedures and timelines, ECHO Reimbursement procedures, cash management of federal funds and training plans/compliance associated with these drawdowns. The procedures have been accepted by the FTA and are now active. Repayment was made to the grant in May 2025 and no penalties were assessed. Responsible Party: Sutton Rowley, FP&A Manager Anticipated Completion Date: Complete and finding was closed on March 24, 2025.
View Audit 364521 Questioned Costs: $1
Midd-West School District
PA
Subrecipient Monitoring Reporting
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.
View Audit 364515
Finding 573853 (2024-001)
Significant Deficiency 2024
Enterprisekc
KS
Procurement, Suspension & Debarment Allowable Costs / Cost Principles
Corrective Action Plan 2024-001: Management has since performed the suspension and debarment check for the vendor and included the check in the contract file for all covered transactions. Anticipated Completion Date: July 2025 Contact Person: Jay Konomos, Pillar Leader
Corrective Action Plan 2024-001: Management has since performed the suspension and debarment check for the vendor and included the check in the contract file for all covered transactions. Anticipated Completion Date: July 2025 Contact Person: Jay Konomos, Pillar Leader
View Audit 364498
Finding 573850 (2024-002)
Significant Deficiency 2024
City of Belview
MN
Internal Control / Segregation of Duties
Segregation of Duties
Segregation of Duties
View Audit 364494
Finding 573850 (2024-002)
Significant Deficiency 2024
City of Belview
MN
Internal Control / Segregation of Duties
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
View Audit 364494
Finding 573850 (2024-002)
Significant Deficiency 2024
City of Belview
MN
Internal Control / Segregation of Duties
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
View Audit 364494
Finding 573850 (2024-002)
Significant Deficiency 2024
City of Belview
MN
Internal Control / Segregation of Duties
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
View Audit 364494
Finding 573847 (2024-001)
Significant Deficiency 2024
City of Belview
MN
Auditor Prepared Financial Statements
Auditor Prepared Financial Statements
View Audit 364494
Finding 573847 (2024-001)
Significant Deficiency 2024
City of Belview
MN
Name of Contact Person: Chelsey Traeger, City Clerk
Name of Contact Person: Chelsey Traeger, City Clerk
View Audit 364494
Finding 573847 (2024-001)
Significant Deficiency 2024
City of Belview
MN
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
View Audit 364494
Finding 573847 (2024-001)
Significant Deficiency 2024
City of Belview
MN
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
View Audit 364494
Finding 573843 (2024-002)
Significant Deficiency 2024
Winnebago County, Wisconsin
WI
Procurement, Suspension & Debarment Subrecipient Monitoring
Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: Ther...
Recommendation: We recommend the County evaluate policies and update to be in accordance with Uniform Guidance. The procurement policy in place does not meet UG requirements, which includes having a policy on suspension and debarment verification. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County is working on reviewing policies and procedures and updating as necessary. Further, they have hired a Management Analyst to help with training and ensuring grant compliance. Name(s) of the contact person(s) responsible for correction action: Carol Van Gruensven Planned completion date for corrective action: Ongoing
View Audit 364493
Finding 573840 (2024-001)
Significant Deficiency 2024
Central Tribes of the Shawnee Area, Inc.
OK
Subrecipient Monitoring Equipment & Real Property Management Internal Control / Segregation of Duties § 200.328
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.
View Audit 364487
Finding 573826 (2024-014)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
View Audit 364483
Finding 573825 (2024-013)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
View Audit 364483
Finding 573824 (2024-012)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
View Audit 364483
Finding 573823 (2024-010)
Material Weakness 2024
Caddo County
OK
Procurement, Suspension & Debarment Internal Control / Segregation of Duties Subrecipient Monitoring
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct complia...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and m a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
View Audit 364483
Franciscan Alliance, Inc.
IN
Procurement, Suspension & Debarment § 200.320
Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to ...
Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to promote sound business practices and effective internal controls across the organization through communication, training, and consistent enforcement of the Franciscan’s policies. The following are the Views and Corrective Action Plans of Management regarding the Schedule of Findings and Questioned Costs for the year ended December 31, 2024 for Franciscan. AUDIT FINDING 2024-001 – Compliance with Reporting Requirements MANAGEMENT’S RESPONSE: Management concurs that the sole source justification was not formally documented prior to the time of procurement. Franciscan’s procurement policy already includes clear criteria for sole source contracting, including the requirement that such procurements be supported by documented justification and approved by the Vice President Supply Chain. The policy outlines specific conditions under which sole source justification is permitted and requires Supply Chain to verify price reasonableness using benchmarking tools or known pricing data. CORRECTIVE ACTION PLAN: Franciscan implemented a new procurement software in the fourth quarter of 2024. The software has a required field for users to select if the procurement is sole-source and if it is, another required field activates for the user to provide a reason for sole-source. Once a procurement request is submitted by the user, the sourcing team reviews the request and verifies it has the appropriate approval if it is sole-sourced. RESPONSIBLE PERSONS: Sarah Burdick, Administrative Director Strategic Sourcing, Franciscan Alliance, Inc. COMPLETION DATE: December 2024
View Audit 364476
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