Corrective Action Plans

Finding 1166493 (2023-008)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Cash Management Reporting § 200.327 § 200.328

Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the fi...

Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the findings; Responsible Individual: Nicole Reinert, Public Health Director; Corrective Action Plan: Administrative staff will schedule out all required report dates in the Outlook calendar at least three weeks before the due date to keep responsible parties informed of deadlines. These set reminders will ensure timely submissions. The Department Head will review the submission process to eliminate congested workflow to ensure efficiency and identify any tasks that can be automated or improved. Regular check-ins will take place to discuss the status of ongoing reports.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166491 (2023-006)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Eligibility Reporting § 200.328

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Manageme...

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Certification Title III Expenditures and Unobligated Funds by statutory deadline. This process should include clear assignment to responsibilities and retention of documentation as part of grant compliance records.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166490 (2023-001)

Material Weakness 2023

County of Plumas

CA

Reporting

Schools and roads - Grants to States, Highway Planning and Construction, Coronavirus State and Local Fiscal Recovery Funds, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Foster Care - Title IV-E, and Medical Assistance Program. We recommend that the County departments provide t...

Schools and roads - Grants to States, Highway Planning and Construction, Coronavirus State and Local Fiscal Recovery Funds, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Foster Care - Title IV-E, and Medical Assistance Program. We recommend that the County departments provide the County Auditor with accurate Federal expenditure information prior to the beginning of audit fieldwork. Management's Response: The County concurs with the findings. Responsible Individuals: 10.665 and 20.205: Rob Thorman, Director of Public Works and Damien Frank, Administrative Services Officer; 10.665: Kevin Goss, Chairman of the Board of Supervisors; 21.027 and 93.323: Nicole Reinert, Director of Public Health and DeLena Jones, Administrative Services Officer; 93.658 and 93.778: Jennifer Bromby, Interim Social Services Director/Staff Service Manager. Corrective Action Plan: Each department will be required to run a trial balance report and identify the federal expenditures by program. The departments will be required to track each program and either within the financial system or on an Excel spreadsheet and at the end of the fiscal year use the method of backing out expenses from previous SEFA reporting and adding any expenses from the subsequent fiscal year to the prior fiscal year up to 60 days. The department tis required to maintain the reconciliation spreadsheet on a monthly or quarterly basis depending on the volume of the program. The department fiscal officer will be required to review with the department head, and both the department fiscal officer and department head will need to sign off on the SEFA information provided to the Auditor-Controller, along with proper back and the program trial balance at the end of the fiscal year prior to start of the external auditor fieldwork. Anticipated Completion Date: The Auditor-Controller will hold a mandatory training course in January of 2026 for fiscal officers and department heads of the above-mentioned findings.

View Audit 377492

Finding 1166456 (2023-001)

Material Weakness 2023

Eastern Kentucky PRIDE, Inc.

KY

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

Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.

View Audit 377479

Finding 1166337 (2023-004)

Material Weakness 2023

Wayne County, Missouri

MO

Procurement, Suspension & Debarment Subrecipient Monitoring

The County will ensure vendors are not suspended or debarred in the future.

View Audit 377436

Finding 1166325 (2023-009)

Material Weakness 2023

Dorchester County, Maryland

MD

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

The County will implement procedures to ensure the review and approval of the monthly report is documented.

View Audit 377392

Finding 1166324 (2023-008)

Material Weakness 2023

Dorchester County, Maryland

MD

Eligibility Matching / Level of Effort / Earmarking § 200.303

The County will implement procedures to ensure the approval process is documented.

View Audit 377392

Finding 1166323 (2023-007)

Material Weakness 2023

Dorchester County, Maryland

MD

Subrecipient Monitoring § 200.303 § 200.332

The County will implement a new policy to ensure all subrecipients that are given federal funds of $25,000 or more are properly monitored.

View Audit 377392

Finding 1166322 (2023-006)

Material Weakness 2023

Dorchester County, Maryland

MD

Procurement, Suspension & Debarment § 200.213 § 200.303

The County will implement a new policy to verify vendors are not suspended or debarred.

View Audit 377392

Finding 1166286 (2023-003)

Material Weakness 2023

Hill Country Community Clinic, Inc.

CA

Cash Management

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.

View Audit 377361

Finding 1166285 (2023-002)

Material Weakness 2023

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 377361

Finding 1166216 (2023-002)

Material Weakness 2023

Fayette County General Health District

OH

Allowable Costs / Cost Principles § 200.430

Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3%...

Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.

View Audit 377197

Finding 1166097 (2023-006)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025

View Audit 376863

Finding 1166095 (2023-005)

Material Weakness 2023

City of Lynn

MA

Procurement, Suspension & Debarment

Audit Finding Reference: 2023-005 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: The City strives to procure services per Federal Guidelines however, Lynn Public Schools provides millions of dollars for services however we need to do a better job to reach 100% com...

Audit Finding Reference: 2023-005 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: The City strives to procure services per Federal Guidelines however, Lynn Public Schools provides millions of dollars for services however we need to do a better job to reach 100% compliance by the time our 2024 Singe Audit is completed. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1166088 (2023-004)

Material Weakness 2023

City of Lynn

MA

Equipment & Real Property Management

Audit Finding Reference: 2023-004 Update Federal Equipment/Real Property Listings (Material Weakness) Planned Corrective Action: The City strives to maintain accurate Fixed Assets, Lynn Public Schools purchase millions of dollars of Equipment using Federal Funds. I will work with the School Business...

Audit Finding Reference: 2023-004 Update Federal Equipment/Real Property Listings (Material Weakness) Planned Corrective Action: The City strives to maintain accurate Fixed Assets, Lynn Public Schools purchase millions of dollars of Equipment using Federal Funds. I will work with the School Business Administrator to track and include these assets annually. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1166078 (2023-003)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles Material Weakness

Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Depa...

Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Department to address this finding. The context below is from CD: Corrective action implemented with City FY24 (07/01/23-06/30/24). Annually, a budget for staff salary and fringe is developed and approved by CD Director Marsh. The annual budget details staff hours and cost centers each will be charged during the year ( e.g. CDBG activity delivery, CDBG admin, Seaport Marina, Auditorium, ESG, etc.). Additionally, employees track time on individual time sheets weekly. This finding was also noted at the last HUD monitoring review, and marked as resolved and closed in June 2024 following HUD's post review. Name of Contact Person and Completion Date James Marsh, Executive Director of The Office of Community Development & Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1166069 (2023-002)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles School Nutrition Programs Significant Deficiency

Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...

Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025

View Audit 376863

Finding 1166049 (2023-001)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles School Nutrition Programs Material Weakness

Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressin...

Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressing that this is a finding and more diligence needs to occur in order to remove this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1165797 (2023-001)

Material Weakness 2023

Family Wellness Outreach Center of Georgia, Inc.

GA

Reporting Significant Deficiency

Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionall...

Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionally, reasonably and in a timely manner to secure our 2022 audit within the required timeline. Despite our diligence, the previous auditing company and their representatives were grossly non-responsive and ultimately, we had to dispute our payment that was made in full for not receiving the 2022 audit services in a timely manner. This impacted our 2023 audit not being completed as indicated in the finding. Corrective Action: The Organization chose a new audit company that is responsive, professional and highly experienced in non-profit audits. The Organization continues to have a process in place to ensure that required audits are completed in accordance with established guidelines. In advance, we seek at least three bids from reputable audit companies; our finance team provides documentation in a timely manner; we utilize a designated person to ensure the audit process is not delayed including conducting routine follow-ups or check-ins and ensuring any issues are resolved quickly; and we pay our bills on time. Our corrective action plan is in place to ensure timely audits in the future as applicable.Name of Contact Person Sophia Nash – HR-Business Manager; 229-854-3660; hr.fwocga@gmail.com Projected Completion Date: December 31, 2025

View Audit 376600

Finding 1165780 (2023-002)

Material Weakness 2023

City of Springfield

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training...

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training to staff on SLFRF reporting requirements and deadlines, implement written policies and procedures to ensure timely submission of all reports, including establishing a compliance calendar with automated reminders and maintaining a reporting log to track submission dates. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Katie Eviston, Finance Director, (937) 324-7700

View Audit 376568

Finding 1165777 (2023-003)

Material Weakness 2023

City of Springfield

OH

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties

Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties ar...

Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties are accurately monitored, and will confirm that responsibility for scheduling and completing inspections is clearly assigned to a designated staff member within the Community Development department. Overdue inspections will be completed promptly, with results documented in accordance with HUD requirements. In addition, the City will review and revise current policies and procedures to strengthen inspection scheduling, address staff turnover contingencies, and improve compliance monitoring. Staff will receive updated training on HUD property standards and inspection requirements to ensure ongoing compliance. Progress will be monitored quarterly, and updates will be provided to management and the governing body. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Logan Cobbs, Community Development Director, (937) 324-7381

View Audit 376568

Finding 1165703 (2023-005)

Material Weakness 2023

Eldred Borough

NY

Internal Control / Segregation of Duties Reporting § 200.303

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.

View Audit 376427

Finding 1165699 (2023-004)

Material Weakness 2023

Eldred Borough

NY

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties § 200.512

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.

View Audit 376427

Finding 1165695 (2023-003)

Material Weakness 2023

Eldred Borough

NY

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties § 200.512

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.

View Audit 376427

Finding 1165680 (2023-022)

Material Weakness 2023

City of Jackson, Mississippi

MS

Cash Management Subrecipient Monitoring Significant Deficiency

Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as iden...

Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as identified. In addition, any project associated with outside funding has gone through or will go through a reconciliation process to evaluate its current standing, including all related receivables and payables, and will continue to do so monthly. The City is working to ensure all invoices are paid within a timely manner of the related award advances and according to application of Federal and State regulations.

View Audit 376388

Corrective Action Plans

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