Corrective Action Plans

Finding 559014 (2024-001)

Significant Deficiency 2024

Community Action Agency of St. Louis County, Inc.

MO

Eligibility Significant Deficiency Internal Control / Segregation of Duties § 200.303

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related ...

CAASTLC acknowledges the timing discrepancy in the documentation of staff review and signature during the drive-through food pantry operations in early 2024. Although eligibility was appropriately determined prior to the distribution of food, we recognize the importance of ensuring that all related documentation is contemporaneously completed and appropriately approved to maintain a strong internal control environment. The current intake and eligibility verification procedures was revised to include explicit language requiring staff signatures and approval of eligibility documentation on the date of service. These updated procedures will reflect both in-office and drive-through (if resumed) operations. All relevant staff members will receive updated training on intake documentation requirements, including the importance of contemporaneous staff review and approval. Training materials will be revised to emphasize compliance with federal requirements related to eligibility documentation. While data entry into MIS may still occur post-service, staff will be required to document and date eligibility approvals on the intake fonns at the time of service. Intake forms will now include a section for immediate staff verification with date stamps to reflect real-time approval. Name of Responsible Person: Linda Huntspon, Chief Executive Officer Anticipated Completion Date: Implemented in January 31, 2025

View Audit 355262

Finding 559010 (2024-001)

Significant Deficiency 2024

Oglala Lakota College

SD

Reporting

Head Start Cluster 93.600 Significant Deficiency Internal Control over Reporting 2024-001 Condition: As of the January 2025 audit fieldwork date, the annual reports (Form SF 425) had not been filed for the years ended July 31, 2023 or July 31, 2024. Criteria: Instructions to Form SF-425, Feder...

Head Start Cluster 93.600 Significant Deficiency Internal Control over Reporting 2024-001 Condition: As of the January 2025 audit fieldwork date, the annual reports (Form SF 425) had not been filed for the years ended July 31, 2023 or July 31, 2024. Criteria: Instructions to Form SF-425, Federal Financial Report, require that quarterly and interim reports be submitted no later than 30 days after the reporting period and annual reports no later than 90 days after the reporting period. The reporting period ends July 31. Auditor’s Recommendation: We recommend that program directors provide information to the Federal Grant Manager timely to ensure reports are completed and submitted within established due dates. As noted, the July 31, 2023 and 2024 reports have since been filed and accepted by the federal agency. Management’s Response: Management will ensure that the Federal Grants Manager has access to all information necessary to submit reports for federal programs. As noted above, the reports were filed in March 2025 and have been accepted by the federal agency. If there are any questions regarding this plan, please contact Tanya Garnenez, Vice President of Business, at 605-455-6011. Respectfully, Tanya Garnenez, Vice President of Business Oglala Lakota College Kyle, South Dakota

View Audit 355250

Finding 559003 (2024-001)

Significant Deficiency 2024

Indiana Health Centers, Inc.

IN

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and inter...

SIGNIFICANT DEFICIENCIES WIC Special Supplemental Nutrition Program for Women, Infants and Children Federal Assistance Listing Numbers: 10.557 2024.001 Recommendation We recommend that management provide training for those responsible for verifying eligibility to ensure that documentation and internal control over eligibility is maintained. Action Taken The agency Coordinator will have a training session with each clerk in the agency on the importance of documentation and completion of assessing WIC eligibility. This re-training will include step-by-step instructions. Clerks will be instructed to add notes when needed to explain a client's eligibility, (ex. immigrants and eligibility). Demonstration will be required by each clerk to their supervisor. The re-education will be completed by the end of June 2025 and reported on a log with attendees. Ongoing monitoring will be performed by agency supervisors. They will audit five charts twice a month for each clerk/certifier. In the event, there are deficiencies identified, the supervisor will re-train the clerk/certifier at that time. 1. A folder for each clerk will be kept in a locked cabinet by the agency supervisor. It will contain a log that will consist of the clerk's name, household audited and an analysis of the eligibility that was completed at the certification. 2. Ongoing corrections if needed will be addressed by the agency supervisor or coordinator. Retraining may be requested by clerical staff at any time. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Mr. Tracy Nagel, CFO at (317) 576-1335 or email to tnagel@ihcinc.org.

View Audit 355246

Finding 559002 (2024-003)

None 2024

Town of Colchester, Ct

CT

Reporting Internal Control / Segregation of Duties

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First S...

The Town has reviewed the reporting procedures and how to maintain accurate expenditures, in accordance with U.S. Treasury guidelines. This corrective action has been sustained for the March 2025 filing, and will be adhered to for any subsequent reporting by the Director of Finance and the First Selectman.

View Audit 355244

Finding 559000 (2024-001)

Material Weakness 2024

Allegheny County Industrial Development Authority

PA

Matching / Level of Effort / Earmarking Reporting § 200.303

Finding 2024-001: Reporting Management Response: The system to record IDA’s loan portfolio has an incorrect cash balance that has been carried forward from prior years. The cash balance is self populated within the reporting system which the Authority can’t correct. The Authority has...

Finding 2024-001: Reporting Management Response: The system to record IDA’s loan portfolio has an incorrect cash balance that has been carried forward from prior years. The cash balance is self populated within the reporting system which the Authority can’t correct. The Authority has reached out to our RLF portfolio manager at the EDA for guidance and resolution. Once corrected, we will have a separate finance team member review the reported cash balance agrees to IDA’s general ledger. Anticipated Completion Date: Immediate

View Audit 355242

Finding 558996 (2024-002)

Material Weakness 2024

Audubon Community School District

IA

Internal Control / Segregation of Duties Reporting

We will continue to review our control procedures to obtain the maximum internal controls possible under the circumstances.

View Audit 355241

Finding 558995 (2024-002)

Significant Deficiency 2024

Almost Home, Inc.

CO

Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

After FY2024, Almost Home ceased using Temporary Assistance for Needy Families (TANF) to cover the cost of Severe Weather Activation Vouchers (SWAP) for TANF-eligible families. From this point forward, TANF will only be used for clients meeting all TANF eligibility requirements.

View Audit 355240

Finding 558991 (2024-001)

Significant Deficiency 2024

Almost Home, Inc.

CO

Reporting § 200.510

Almost Home has begun establishing and finalizing a formal SEFA preparation schedule. Almost Home will also be retaining a CPA/Audit Consultant to work with the staff and conduct periodic reviews of the audit process and status.

View Audit 355240

Finding 558986 (2024-006)

Material Weakness 2024

Dakota Rural Water District

ND

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.318 § 200.326

Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written p...

Environmental Protection Agency, passed through State of North Dakota Department of Environmental Quality Federal Financial Assistance Listing 66.468 Capitalization Grants for Drinking Water Procurement, Suspension, Debarment Material Weakness Finding Summary: The District did not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Jordyne Lee, General Manager Corrective Action Plan: The District will review the applicable 2 CFR 200 sections and implement procedures necessary to ensure compliance with all of these requirements. Anticipated Completion Date: December 31, 2025.

View Audit 355234

Finding 558985 (2024-006)

Material Weakness 2024

Shelter and Assistance in Family Emergencies, Inc.

MS

Questioned Costs Internal Control / Segregation of Duties Cash Management

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual wil...

Management concurs with the finding and has agreed to implement the recommended procedures. Management has also: 1) hired a Director of Finance to oversee financial reporting; 2) implemented a monthly grant reconciliation process; 3) implemented segregation of duties so that no single individual will be responsible for preparing reimbursement requests and subsequently submitting them; 4) provided extensive training to staff involved in the grant reimbursement procedures; 5) implemented a centralized grant tracking sheet to monitor billed amounts by category and date that is verified by two staff members; 6) implemented a quarterly internal audit review by a Board of Directors member with any findings reported to the Board of Directors for oversight.

View Audit 355230 Questioned Costs: $1

Finding 558984 (2024-002)

None 2024

Grandview Apartments, Inc.

PA

Questioned Costs HUD Housing Programs Reporting

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 o...

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management made a $11,400 deposit on 1/17/2025. The Project finally received the outstanding 2024 subsidy payments in February 2025 and Management made the additional deposit of $4,600 on 3/25/2025. The finding is cleared.

View Audit 355222 Questioned Costs: $1

Finding 558983 (2024-001)

None 2024

Grandview Apartments, Inc.

PA

Questioned Costs HUD Housing Programs Reporting

Those charged with governance agree with the finding and recommendation Reporting Views of Responsible Officials: Management submitted a Form 9250 Fund Authorization on March 26, 2025 for combined 2024 unapproved withdrawals and additional 2025 fund requests. Management is awaiting approval.

View Audit 355222 Questioned Costs: $1

Finding 558982 (2024-002)

None 2024

Calvin Court, Atlanta, Inc.

GA

Cash Management HUD Housing Programs Internal Control / Segregation of Duties

Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes tha...

Recommendations: We recommend the Organization implement additional procedures during year-end close out procedures to ensure residual receipt deposits due at year-end are deposited in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.

View Audit 355218

Finding 558981 (2024-001)

None 2024

Calvin Court, Atlanta, Inc.

GA

Internal Control / Segregation of Duties

Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are...

Recommendations: We recommend the Organization implement and follow a checklist of procedures for moveout occurrences to ensure security deposits due upon move-out are returned in a timely manner. Management agrees with the recommendations and to adhere to current internal control processes that are in place to ensure the Organization is in compliance with all requirements as it relates to their federal awards.

View Audit 355218

Finding 558976 (2024-001)

Significant Deficiency 2024

Community Health Center Dba Alluvion Health, Inc.

MT

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

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The inform...

Corrective Action: 1. Sliding fee applications have been streamlined to provide registration colleagues with a more efficient process. 2. Registration and billing colleagues have received and will continue to receive ongoing training on the sliding fee discount application and process. 3. The information provided for the training will be translated to a process document and provided to all registration staff and billers. Colleagues will be expected to use this document as reference guide to improve program adherence. 4. Registration colleagues will participate in a peer review process where each colleague reviews 5 accounts monthly. They will audit demographics and insurance, as well as slide fee program adherence. Feedback will be provided to the colleagues responsible for errors to make corrections. 5. A leadership team member supervising patient registration colleagues will continue to audit 50 patient accounts each month. The accounts selected will have at least one billable medical, behavioral health, SUD, or dental encounter in the audit month. The audit criteria will include identifying the colleague responsible for inputting income information and application of discounts. Errors identified through the audit process will be sent to the colleage responsible for correction. Supervision and coaching will be provided to colleagues while fixing their errors to improve future performance. Responsible Party(s): Melissa Darko, Revenue Cycle Director and Lisa DeMallie, Associate Vice President of Patient Experience Estimated Completion Date: Applications were streamlined in March 2025; training was provided in April 2025 and will be ongoing; a process document will be provided to staff in May 2025; peer reviews were started in February 2025; and auditing has been ongoing and will continue.

View Audit 355210

Finding 558975 (2024-001)

Material Weakness 2024

City of Diamond Bar

CA

Subrecipient Monitoring Material Weakness Reporting

Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the...

Corrective Action: The City acknowledges the finding regarding noncompliance with the continuing loan monitoring requirements for the Community Development Block Grant (CDBG) Home Improvement Program. We recognize the importance of ensuring full compliance with all grant requirements to maintain the integrity and effectiveness of the program. Training and Awareness: The City will provide comprehensive training to all relevant staff/consultants on the continuing loan monitoring requirements outlined in the LACDA grant agreement and CDBG program guidelines. Training sessions will be completed by June 30, 2026. Policy and Procedure Updates: The City will review and update its internal policies and procedures to clearly document the continuing loan monitoring process. A standardized compliance checklist and loan monitoring schedule will be developed to ensure consistent implementation across all loans. Loan Monitoring and Documentation: By June 30, 2026 the City will implement a regular schedule for evaluating outstanding loans, including, borrower compliance reviews, and follow-up actions where necessary. All monitoring activities will be fully documented and retained in each loan file. Ongoing Oversight: Management will assign a designated staff member/consultant responsible for overseeing the continuing loan compliance process, ensuring ongoing adherence to program requirements and addressing any issues promptly. The City is committed to strengthening internal controls, ensuring compliance with grant requirements, and maintaining the credibility of the Home Improvement Program. Proposed Completion Date: The corrective actions outlined above will be fully implemented by June 30, 2026.

View Audit 355203

Finding 558971 (2024-006)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Student Financial Aid Special Tests & Provisions Eligibility

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system ...

All Students who were not reported were entered into the NSLDS website and their records were updated. A process has been established to capture all official and unofficial withdrawal. The Financial Aid and Registrars offices have developed a system to capture all withdrawals in our new FAMS system (Banner from Ellucian). All students who have withdrawn are being updated through National Student Clearinghouse and from there to NSLDS.

View Audit 355176

Finding 558969 (2024-005)

Material Weakness 2024

Polytechnic University of Puerto Rico, Inc.

PR

Questioned Costs Procurement, Suspension & Debarment § 200.319 § 200.320

Revise and standardize the Sole Provider Justification form to require all federally mandated elements under 2 CFR 200.320. Train all staff involved in procurement activities on the updated requirements and documentation standards. Implement a review and approval step within the new ERP system to ve...

Revise and standardize the Sole Provider Justification form to require all federally mandated elements under 2 CFR 200.320. Train all staff involved in procurement activities on the updated requirements and documentation standards. Implement a review and approval step within the new ERP system to verify that all sole-source procurements meet the full documentation standards before processing. Conduct periodic internal audits of procurement files to ensure continued compliance. Require management approval for any noncompetitive procurement exceeding micro-purchase thresholds.

View Audit 355176 Questioned Costs: $1

Finding 558965 (2024-004)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Monitor compliance through regular internal reviews and sample audits of personnel records.

View Audit 355176

Finding 558956 (2024-003)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Cash Management Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303

Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. C...

Add a new staff member to the Federal Funds Office to strengthen segregation of duties. Update and document internal procedures to ensure proper role separation in the drawdown process. Leverage the upcoming implementation of a new ERP system to support workflow automation and enforce segregation. Conduct training to clarify and reinforce individual roles and responsibilities. Introduce periodic internal reviews to verify compliance with segregation protocols.

View Audit 355176

Finding 558949 (2024-002)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.305

Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the G...

Transfers and Disbursement process will be reviewed to minimize the time between drawdown and disbursement and comply with Federal regulations. Funds are regularly monitored to ensure that only needed funds for immediate use are drawdown. Drawdowns are initiated when accounting department send the Grant monthly reconciliation to Federal and State Funds Administration Office, Compliance officer reviews the reconciliation and Director of Federal Funds Administration determine needed funds to be requested. A new Enterprise Resource Planning (ERP) software it’s under implementation and will address this issue as part of the implementation process.

View Audit 355176

Finding 558946 (2024-001)

Significant Deficiency 2024

Polytechnic University of Puerto Rico, Inc.

PR

Allowable Costs / Cost Principles Student Financial Aid Cash Management

Update internal financial aid disbursement policies to require annual and mid-year reviews of Pell Grant schedules. Implement a compliance checklist for verifying disbursement amounts.

View Audit 355176

Finding 558941 (2024-002)

Significant Deficiency 2024

Fisk University

TN

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financ...

Management concurs with the finding. The new ERP system implementation and first year of operations resulted in delays in timely preparation for the audit. In addition, the unexpected loss of the audit liaison contributed to further delay. The University has begun strengthening its year-end financial reporting and audit preparation processes. Items that can be compiled prior to year-end will be identified and the compilation of those items will begin. Areas that presented challenges during the FY 24 audit will be given special attention in advance. Lastly, audit assignments will be delegated to improve response efficiency. A detailed closing schedule has been developed. Staff duties and responsibilities have been reassigned and repurposed to improve processing timelines and audit preparation. The audit timeline will be monitored more closely to ensure timely responses to audit requests that support the timely completion and issuance of the audit to meet Uniform Guidance timeline requirements.

View Audit 355168

Finding 558936 (2024-001)

Significant Deficiency 2024

Fisk University

TN

Student Financial Aid Cash Management Matching / Level of Effort / Earmarking

Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdow...

Management concurs with the finding. The specific occurrences will be reviewed to determine the cause. In addition, the procedure to facilitate drawdowns after funds have been disbursed will be reemphasized to ensure compliance with the three-business day disbursement rule from the time of drawdown. The Student Financial Aid Office (SFA) will authorize Title IV awards and notify the Bursar and the Grants Account. The Bursar will facilitate disbursement of the funds to the students’ accounts and notify the Grants Accountant once the disbursement has been processed. The Grants accountant will facilitate the drawdown of funds after the funds have been disbursed. This will mitigate the potential recurrence of funds being drawn down prior to being disbursed to students’ accounts resulting in the potential for noncompliance with the three-day window.

View Audit 355168

Finding 558935 (2024-010)

Material Weakness 2024

Lafayette City_parish Consolidated Government

LA

Procurement, Suspension & Debarment

U.S. DEPARTMENT OF TREASURY: Coronavirus Capital Projects Fund (21.029) 2024-010 Controls over Suspension and Debarment Recommendation: The Government should review their established controls, policies and procedures to ensure that the verification of vendors is done prior to doing business with ...

U.S. DEPARTMENT OF TREASURY: Coronavirus Capital Projects Fund (21.029) 2024-010 Controls over Suspension and Debarment Recommendation: The Government should review their established controls, policies and procedures to ensure that the verification of vendors is done prior to doing business with them. Corrective Action Plan: The Government agrees with this finding. Purchasing is normally alerted to verify suspension and debarment status when PO’s are issued in designated federal grant funds. However, we have a few departments that do not report grants in separate funds. If these departments do not identify that a federal grant is the funding source when initiating the procurement process, then Purchasing is not aware that the verifications need to be made. We will review the documentation requirements with the appropriate departments so that purchases made with grant funds in these departments are properly identified. We do not expect this finding to reoccur.

View Audit 355166

Corrective Action Plans

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