Corrective Action Plans

Finding 1156982 (2024-002)

Material Weakness 2024

IN

Allowable Costs / Cost Principles § 200.430

Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepar...

Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepare semiannual attestation for management to review staff allocations. Contact Michael A. Nino, Chief Financial Officer anino@shalomhealthcenter.org 317-269-7198

View Audit 369288

Finding 1156978 (2024-002)

Material Weakness 2024

Wiyot Tribe

CA

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Management’s Response The Department Director changed in April of 2024, mid grant. The Director was unable to access the portal needed to submit reports. The process to change the PI for this grant, which started in 2024, took some time for the grantor to complete. After gaining access, reports were...

Management’s Response The Department Director changed in April of 2024, mid grant. The Director was unable to access the portal needed to submit reports. The process to change the PI for this grant, which started in 2024, took some time for the grantor to complete. After gaining access, reports were finally submitted in June 2025. The Tribe has implemented an online grant management system (CGMS) to accurately record and track all approved grants. This system enables department directors to generate reports within the platform and notify responsible parties via email for each report. The TA oversees these reports and can identify those that have not been submitted, reminding responsible parties to meet deadlines. With enhanced internal controls, the Tribe has successfully submitted nearly all required FFRs and PPRs on time. This system also helps onboard new directors of their grant requirements, documents and report deadlines. Another step the Tribe took to prevent such findings was developing a grant application checklist. The Tribal Administrator created a checklist, approved by the Tribal Council, to guide Department Directors on how to apply for grants and meet their requirements, including reporting. We will address this finding by establishing a clear grant report procedure which will outline step by step procedures required by the Tribe's Fiscal Management policies. Anticipated Completion Date December 31, 2025 Responsible Party Michelle Vassel, Tribal Administrator Farzad Forouhar, Fiscal Manager

View Audit 369286

Finding 1156977 (2024-001)

Material Weakness 2024

Wiyot Tribe

CA

Subrecipient Monitoring

Management’s Response This grant was written and submitted by an outside third party, and the Tribe did not have access to the original grant application, the grant terms, or the portal where the grant was housed. After the grant began, the Tribe faced pushback from some sub-recipient entities regar...

Management’s Response This grant was written and submitted by an outside third party, and the Tribe did not have access to the original grant application, the grant terms, or the portal where the grant was housed. After the grant began, the Tribe faced pushback from some sub-recipient entities regarding the controls over subrecipient monitoring that the Tribe tried to establish, to the point where some entities considered leaving the program entirely. The Tribal Administrator developed a Grant Application Checklist, approved by the Tribal Council, to assist Departments in applying for grants and fulfilling their requirements. This grant submission policy prohibits Tribal departments from having third-party entities write and submit on their behalf Regarding ALN#84.229A, the noted policies will require sub-recipients to agree to these policies provided by the Wiyot Tribe, which include that payments will be made only on a reimbursement basis and will not be processed unless sufficient documentation is provided to the Tribal Administrator or her designee. We will address this finding by establishing a clear sub-recipient monitoring procedure. This procedure will outline the step-by-step process to be followed when the tribe contracts with a subrecipient to expend grant funds. Anticipated Completion Date December 31, 2025 Responsible Party Michelle Vassel, Tribal Administrator Farzad Forouhar, Fiscal Manager

View Audit 369286

Finding 1156976 (2024-001)

Material Weakness 2024

Public Hospital District No. 1 of Skagit County

WA

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Correct...

Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Corrective Action: January of 2022 saw a massive uptick in daily Covid-19 cases across the country. As a result of this crisis, the incident command (IC) structure established a labor pool that deployed volunteers into unfilled shifts at the hospital for a myriad of critical positions. These shifts were tracked and coordinated via the incident command structure on separate worksheets and as a result worked shifts were not coded directly on employee timecards as had been done previously over the course of the pandemic. All other payroll submissions of the county will refer to timecard-coded worked hours and expenses, which allow the user to generate standard payroll cost reports directly out of source financial systems rather than manually matching multiple data sources to calculate relevant costs

View Audit 369262

Finding 1156975 (2024-001)

Material Weakness 2024

Lowcountry Aids Services, Inc.

SC

Reporting § 200.512

Recommendation: The Organization should establish and implement formal procedures to ensure timely submission of its single audit reporting package to the Federal Audit Clearinghouse. Planned Corrective Actions: The Organization is in the process of filing the delinquent single audit reporting packa...

Recommendation: The Organization should establish and implement formal procedures to ensure timely submission of its single audit reporting package to the Federal Audit Clearinghouse. Planned Corrective Actions: The Organization is in the process of filing the delinquent single audit reporting packages with the Federal Audit Clearinghouse. In addition, the Organization has assigned the responsibility for filing the single audit reporting package to its Chief Financial Officer and has developed a compliance calendar to track the submission deadline. If there are any questions regarding this corrective action plan, please contact Jill Barnes, Chief Financial Officer, at (843) 747-2273.

View Audit 369258

Finding 1156971 (2024-001)

Material Weakness 2024

County of Middlesex

NJ

Reporting § 200.327 § 200.328

Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.

View Audit 369257

Finding 1156970 (2024-002)

Material Weakness 2024

County of Middlesex

NJ

Matching / Level of Effort / Earmarking Reporting § 200.302 § 200.327

Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.

View Audit 369257

Finding 1156923 (2024-006)

Material Weakness 2024

Northeast Iowa Workforce Development Board

IA

Material Weakness Reporting

Management will ensure all requested information is available for the auditor in order to facilitate timely completion of the audit by March 31.

View Audit 369256

Finding 1156922 (2024-005)

Material Weakness 2024

Northeast Iowa Workforce Development Board

IA

Internal Control / Segregation of Duties

Management will work with the fiscal agent to strengthen controls by ensuring more than one employee is involved in processing and recording cash transactions. In addition, management will provide board oversight thorugh periodic review of financial activity.

View Audit 369256

Finding 1156921 (2024-003)

Material Weakness 2024

Northeast Iowa Workforce Development Board

IA

Internal Control / Segregation of Duties Reporting Significant Deficiency

Management will work with the fiscal gaent ot create and maintain a separate general ledger.

View Audit 369256

Finding 1156911 (2024-001)

Material Weakness 2024

The Maggie Walker Community Land Trust

VA

Cash Management Reporting

1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations ...

1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations and Real Estate and CEO will be carbon copied on all reporting submissions for federal grants. 4. We are committed to achieving full compliance by December 31, 2025, with the CEO overseeing the process.

View Audit 369253

Finding 1156910 (2024-002)

Material Weakness 2024

Future Harvest, Inc.

MD

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.334 § 200.403

Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies...

Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies. Senior staff will review payroll data to ensure calculations are being made and reported. Expected Completion Date: The Organization expects all findings to be resolved by December 31, 2025

View Audit 369250 Questioned Costs: $1

Finding 1156907 (2024-003)

Material Weakness 2024

Central Minnesota Council on Aging

MN

Matching / Level of Effort / Earmarking Material Weakness Reporting

Older Americans Act Title III – Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Organization should review and approve reports before submitting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Ma...

Older Americans Act Title III – Assistance Listing No. 93.044, 93.045, 93.053 Recommendation: The Organization should review and approve reports before submitting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the financial reports that are prepared by staff before submitting the report and will document that review/approval. Name(s) of the contact person(s) responsible for corrective action: Lori Vrolson, Executive Director Planned completion date for corrective action plan: 12/31/25

View Audit 369244

Finding 1156892 (2024-003)

Material Weakness 2024

Bossier Office of Community Services, Inc.

LA

Reporting

Management have contracted a CPA to work with Financial staff to ensure the accuracy of financial records. A schedule of financial activities is in place the include due date for submission of Federal Financial Report (SF-425) Executive Director will monitor the financial records of submission and r...

Management have contracted a CPA to work with Financial staff to ensure the accuracy of financial records. A schedule of financial activities is in place the include due date for submission of Federal Financial Report (SF-425) Executive Director will monitor the financial records of submission and report to the Board of directors.

View Audit 369240

Finding 1156891 (2024-002)

Material Weakness 2024

Bossier Office of Community Services, Inc.

LA

Internal Control / Segregation of Duties

Management have contracted a CPA to work with Financial staff to ensure the accuracy of financial records. CPA will review financial record monthly for accuracy to ensure the Board of Directors receive accurate financial information.

View Audit 369240

Finding 1156890 (2024-001)

Material Weakness 2024

Bossier Office of Community Services, Inc.

LA

Matching / Level of Effort / Earmarking § 200.302

Management have contracted a CPA to work with Financial staff to ensure the accuracy of revenue and expense transactions. CPA will review revenue and expense statements monthly and make any necessary corrections. D. Compliance – Uniform

View Audit 369240

Finding 1156886 (2024-004)

Material Weakness 2024

Hearts for the Invisible Charlotte Coalition

NC

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management § 200.303 § 200.328 § 200.430

Each employee will have a payroll file that includes: • Date of hire • Title • Grant(s) they are assigned to if applicable • Pay amount • Any changes to the above and the date of the change Each employee will complete a timesheet weekly that includes the number of hours worked and if applicable brok...

Each employee will have a payroll file that includes: • Date of hire • Title • Grant(s) they are assigned to if applicable • Pay amount • Any changes to the above and the date of the change Each employee will complete a timesheet weekly that includes the number of hours worked and if applicable broken out by what grant(s) they worked on. The bookkeeper provides a budget:actual report when invoices for federal contracts are prepared. The ED notes signs off that they have been approved for draw. That report is stored on the server. The Treasurer reviews the cost-reimbursement requests prepared by the ED, along with the detailed back up.

View Audit 369236

Finding 1156885 (2024-003)

Material Weakness 2024

Hearts for the Invisible Charlotte Coalition

NC

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.320

Adopting procurement policy that complies with UG procurement standards and distributed it to all staff with purchasing authority. The ED and Treasurer are currently developing a checklist that will be included as part of initiating contracts or purchases over the procurement threshold and that it i...

Adopting procurement policy that complies with UG procurement standards and distributed it to all staff with purchasing authority. The ED and Treasurer are currently developing a checklist that will be included as part of initiating contracts or purchases over the procurement threshold and that it is saved along with other grant documents. The bookkeeper will check the SAM data base for disbarment notices prior to queuing bills for amounts greater than $5,000 for payment

View Audit 369236

Finding 1156884 (2024-002)

Material Weakness 2024

Hearts for the Invisible Charlotte Coalition

NC

Reporting Internal Control / Segregation of Duties § 200.510 § 200.518

Executive Director will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly • ED will ensure we have written documentation for all federal pass-through funding with correct ALN numbers and communicate the information to the t...

Executive Director will work with all program areas to ensure that all federal awards and subawards are identified as such to ensure we track properly • ED will ensure we have written documentation for all federal pass-through funding with correct ALN numbers and communicate the information to the third party accountants • ED will verify the federal nature of all awards and stay current on SEFA and Uniform Guidance

View Audit 369236

Finding 1156883 (2024-002)

Material Weakness 2024

Housing Authority of St. Louis County

MO

Questioned Costs Special Tests & Provisions Eligibility

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879 & 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to ...

Finding 2024-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879 & 14.EHV Noncompliance – N. Special Tests and Provisions – Selections from the Waiting List Non Compliance Material to the Financial Statements: No Significant deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Selections from the Waiting List. The PHA must have written policies in its HCVP administrative plan for selecting applicants from the waiting list and PHA documentation must show that the PHA follows these policies when selecting applicants from the waiting list. Except for as provided in 24 CFR section 982.203(Special admission (non-waiting list)), all families admitted to the program must be selected from the waiting list. “Selection” from the waiting list generally occurs when the PHA notifies a family whose name reaches the top of the waiting list to come in to verify eligibility for admission (24CFR sections 5.410, 982.54(d), and 982.201 through 982.207). Condition: Based upon inspection of the waiting list provided to us during the time of audit, the new move-in list and discussions with management, it could not be determined with any certainty that new move-ins were selected from the wait list in an order that is in accordance with the Authority’s policy. Context: Twenty-five (25) names were selected from the new move-in list and those names were to be traced to the waiting list to verify new move-ins were chosen in an order that was in accordance with the Authority’s policy. It was determined that one (1) out of twenty-five (25) new move-ins selected could not be traced with any certainty back to the Authority's waiting list. Known Questioned Costs: $9,231 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to selections from the waiting list. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster programs are in non-compliance with the special tests and provisions type of compliance related to selections from the waiting list. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority has recognized the significant deficiency in the Housing Voucher Cluster programs and will implement internal control procedures that will ensure compliance with federal regulations. Nicole Alexander, HCV Program Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 369232 Questioned Costs: $1

Finding 1156882 (2024-001)

Material Weakness 2024

Housing Authority of St. Louis County

MO

Questioned Costs HUD Housing Programs Special Tests & Provisions

Finding 2024-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879, & 14.EHV Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the F...

Finding 2024-001: Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871, 14.879, & 14.EHV Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least annually to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were failed inspections that did not pass reinspection within 30 days without penalty. Context: There are approximately 405 units with failed inspections. Of a sample size of twenty-five (25) failed inspections, two (2) failed inspections did not pass reinspection within 30 days. HAP was not abated nor was the tenant evicted. Our sample size is statistically valid. Known Questioned Costs: $330 Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. The Authority has not properly performed HQS inspections in compliance with program requirements following the expiration of HUD waivers as a result of insufficient staffing. Effect: The Housing Voucher Cluster programs are in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor, and will design and implement internal controls over compliance in order to ensure all necessary failed HQS inspections with life threatening deficiencies are addressed within 24 hours and all other deficiencies are addressed within 30 days. Nicole Alexander, HCV Program Director, is responsible for implementing this corrective action by December 31, 2025.

View Audit 369232 Questioned Costs: $1

Finding 1156879 (2024-002)

Material Weakness 2024

City of Wausau

WI

Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.214

Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the ...

Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Initially, the city was documenting the work performed on suspension and debarment through the creation of a list. In September 2024, the auditor's recommendation was to snip the search and note the search date. The city initiated this process immediately after the finding. Unfortunately, the test sample selected for the audit work was for purchases made in early 2024, before the new method was implemented. We have provided documentation of the new process and will continue to use it in the future. Name(s) of the contact person( responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2025 If the U.S. Department of the Treasury has questions regarding this plan, please call Maryanne Groat, Finance Director, at 715-261-6645.

View Audit 369230

Finding 1156878 (2024-001)

Material Weakness 2024

County of Wayne, New York

NY

Student Financial Aid Eligibility

The County will ensure that procedures are in place to ensure support is provided for review and approval of eligibility determination.

View Audit 369225

Finding 1156877 (2024-004)

Material Weakness 2024

Laporte County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2024-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effec􀆟ve internal control system, which would include segrega􀆟on of du􀆟es, was not in place at the County in order to...

FINDING 2024-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effec􀆟ve internal control system, which would include segrega􀆟on of du􀆟es, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the procurement and suspension and debarment compliance. Prior to entering into subawards and covered transac􀆟ons with Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, recipients are required to verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded. Upon inquiring of the County to determine its policies and procedures related to suspension and debarment requirements for the CSLFRF, SLFRF funds, the County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transac􀆟ons. The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from par􀆟cipa􀆟on in federal assistance programs or ac􀆟vi􀆟es during the audit period on all of the 13 vendors determined to have covered transac􀆟ons totaling $4,440,497, that were paid with SLFRF funds. The lack of internal controls and compliance under the previous Auditor Timothy J. Stabosz were systemic issues throughout the audit period. Contact Person Responsible for Correc􀆟ve Ac􀆟on: Michael Rosenbaum Contact Phone Number and Email Address: 219-326-6808 Ext. 2226; mrosenbaum@laporteco.in.gov Views of Responsible Official: We concur with the finding under the prior Auditor Timothy J. Stabosz. Descrip􀆟on of Correc􀆟ve Ac􀆟on Plan: Policies and procedures will be put in place to search on sam.gov to determine if a vendor has been suspended or disbarred. The County will implement a checklist to capture the procedure to confirm vendors paid from this program were not suspended or disbarred. An􀆟cipated Comple􀆟on Date: December 2025

View Audit 369224

Finding 1156876 (2024-012)

Material Weakness 2024

State of Missouri

MO

Subrecipient Monitoring § 200.303 § 200.332

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: State Emergency Management Agency Audit Finding Number: 2024-012 - SEMA Subrecipient Monitoring Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for corr...

State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: State Emergency Management Agency Audit Finding Number: 2024-012 - SEMA Subrecipient Monitoring Name of the contact person responsible for corrective action: Nikol Enyart Anticipated completion date for corrective action: Implemented Corrective action planned is as follows: Since the discovery of the shortfall in the monitoring of subrecipients, SEMA has taken action to get the program back on track. SEMA has maintained forward momentum on completing the risk assessments during the time dictated by the policy. SEMA has also completed 46 out of 107 desk monitoring reports for the medium risk subrecipients, and SEMA has completed 17 out of 83 site visits for high risk subrecipients. SEMA has also cross trained multiple employees in the steps and processes to achieve high outputs for this process. SEMA has created a separate tracker to focus directly on the desk monitoring and site visits that have been completed or still need to be completed. This tracker is monitored by the Deputy Recovery Division Manager. SEMA also generates reports on the 15th and 30th of each month outlining any progress made during those two weeks, and those reports are submitted to the Recovery Division Manager. This report was first created and submitted on January 31, 2025. In relation to the A-133 audits, SEMA has implemented cross training for staff that will ensure should one employee leave, the task will continue without disruption. Two staff are now trained and will submit a report each quarter to the Deputy Fiscal Manager to ensure compliance with the A-133 requirements.

View Audit 369219

Corrective Action Plans

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