Corrective Action Plans

Finding 1215826 (2025-200)

Material Weakness 2025

State of Connecticut Drinking Water Fund - State Revolving Fund

CT

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Recommendation: The Department of Public Health should strengthen internal controls over cash management to ensure that federal drawdowns align with the immediate cash needs to administer the program. Corrective Action Plan as Reported by the Department of Public Health: Management Assurance and Fis...

Recommendation: The Department of Public Health should strengthen internal controls over cash management to ensure that federal drawdowns align with the immediate cash needs to administer the program. Corrective Action Plan as Reported by the Department of Public Health: Management Assurance and Fiscal have worked together to identify gaps and inefficiencies in the drawdown tool. Management Assurance will periodically evaluate the drawdown tool’s usefulness and effectiveness as a cash management internal control. Fiscal will continue to monitor grant draws through the use of the improved drawdown tool. Anticipated Completion Date: Ongoing Department of Public Health Contact Person: Chuma Amechi, Fiscal Administrative Manager chukwuma.amechi@ct.gov (860) 509-7233 Ryan Wenzel, Supervising Accounts Examiner ryan.wenzel@ct.gov (860) 509-7822

View Audit 402418

Finding 1215824 (2025-025)

Material Weakness 2025

State of Connecticut Drinking Water Fund - State Revolving Fund

CT

Eligibility Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.403

Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational ...

Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational Protocol. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees in part with this finding. Condition #1: DSS agrees that participation end dates were not updated timely due to cross-system manual entry limitations. Reconciliation procedures and supervisory oversight will be strengthened. Condition #2: DSS agrees that participation suspensions were not consistently reflected across systems due to timing delays. Monitoring and real-time reconciliation controls will be enhanced. Condition #3: DSS agrees approved costs exceeded institutional thresholds in limited cases. Variances were clinically justified, reviewed, and authorized. DSS will strengthen documentation and internal protocols to ensure clearer policy alignment. Condition #4: DSS agrees that the documentation was incomplete in one instance. Internal review standards will be reinforced to ensure comparative cost analyses are consistently documented. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012

View Audit 402418

Finding 1215786 (2025-100)

Material Weakness 2025

State of Connecticut Drinking Water Fund - State Revolving Fund

CT

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.317 § 200.403

Recommendation: The Department of Transportation should strengthen internal controls over consultant payments for extra work. Corrective Action Plan as Reported by the Department of Transportation: The CTDOT Transit Design Unit has immediately put in-place a corrective action plan, which will be com...

Recommendation: The Department of Transportation should strengthen internal controls over consultant payments for extra work. Corrective Action Plan as Reported by the Department of Transportation: The CTDOT Transit Design Unit has immediately put in-place a corrective action plan, which will be completed by January 30, 2026. As part of this action plan, when signing off on invoices in the future, the Project Manager will ensure the date of the invoice refers to the correct payment mechanism or extra work letter in accordance with our established policies. This will strengthen internal controls and reviews over payments for all fee letters to ensure it follows established policies and only pay for properly authorized extra work. In addition to internal actions, the consultant project team will be counseled for submitting an invoice that does not follow CTDOT policies. Anticipated Completion Date: January 30, 2026 Department of Transportation Contact Person: Jonathan Kang, Transportation Supervising Engineer Jonathan.Kang@ct.gov, (860) 594-2754

View Audit 402418

Finding 1215729 (2025-003)

Material Weakness 2025

YWCA of Greater Portland

OR

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.430

Management agrees with the finding. The Agency’s current approach was designed to balance compliance needs with limited resources. Management will assess feasible improvements to its documentation practices to enhance support for payroll allocations to federal awards while remaining mindful of fundi...

Management agrees with the finding. The Agency’s current approach was designed to balance compliance needs with limited resources. Management will assess feasible improvements to its documentation practices to enhance support for payroll allocations to federal awards while remaining mindful of funding and staffing constraints.

View Audit 402403

Finding 1215720 (2025-001)

Material Weakness 2025

Monroe School District No. 103

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

The district will implement a process to create and maintain documentation for supplemental contracts and substitute employees serving in vacant positions that clearly identifies the applicable cost objectives and includes employee signatures. These records will be retained and maintained for audit ...

The district will implement a process to create and maintain documentation for supplemental contracts and substitute employees serving in vacant positions that clearly identifies the applicable cost objectives and includes employee signatures. These records will be retained and maintained for audit purposes.

View Audit 402385

Finding 1215710 (2025-003)

Material Weakness 2025

Marysville School District No. 25

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Con...

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Conduct a districtwide review of all federally funded positions to ensure appropriate time-and-effort documentation requirements are identified and applied. • Implement standardized procedures for time-and-effort documentation, including the use of semi-annual certifications, monthly personnel activity reports (PARs), or approved fixed schedule systems, as applicable. • Revise and formalize written procedures governing time-and-effort reporting to ensure clarity, consistency, and compliance. • Establish a secondary review process to verify completeness and accuracy of employee classifications and required documentation. • Provide training to applicable staff on time-and-effort requirements and documentation standards. • Implement ongoing monitoring and periodic internal reviews to ensure documentation is completed timely, properly approved, and retained in accordance with requirements. These actions are designed to ensure payroll costs charged to federal programs are fully supported, accurate, and compliant with applicable laws and regulations.

View Audit 402363

Finding 1215706 (2025-004)

Material Weakness 2025

Marysville School District No. 25

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Con...

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Conduct a districtwide review of all federally funded positions to ensure appropriate time-and-effort documentation requirements are identified and applied. • Implement standardized procedures for time-and-effort documentation, including the use of semi-annual certifications, monthly personnel activity reports (PARs), or approved fixed schedule systems, as applicable. • Revise and formalize written procedures governing time-and-effort reporting to ensure clarity, consistency, and compliance. • Establish a secondary review process to verify completeness and accuracy of employee classifications and required documentation. • Provide training to applicable staff on time-and-effort requirements and documentation standards. • Implement ongoing monitoring and periodic internal reviews to ensure documentation is completed timely, properly approved, and retained in accordance with requirements. These actions are designed to ensure payroll costs charged to federal programs are fully supported, accurate, and compliant with applicable laws and regulations.

View Audit 402363

Finding 1215701 (2025-002)

Material Weakness 2025

Marysville School District No. 25

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Con...

The District concurs with the finding and will implement a comprehensive corrective action plan to strengthen internal controls over time-and-effort reporting and ensure full compliance with federal regulations and OSPI guidance, including OSPI Bulletin 039-24. Specifically, the District will: • Conduct a districtwide review of all federally funded positions to ensure appropriate time-and-effort documentation requirements are identified and applied. • Implement standardized procedures for time-and-effort documentation, including the use of semi-annual certifications, monthly personnel activity reports (PARs), or approved fixed schedule systems, as applicable. • Revise and formalize written procedures governing time-and-effort reporting to ensure clarity, consistency, and compliance. • Establish a secondary review process to verify completeness and accuracy of employee classifications and required documentation. • Provide training to applicable staff on time-and-effort requirements and documentation standards. • Implement ongoing monitoring and periodic internal reviews to ensure documentation is completed timely, properly approved, and retained in accordance with requirements. These actions are designed to ensure payroll costs charged to federal programs are fully supported, accurate, and compliant with applicable laws and regulations.

View Audit 402363

Finding 1215687 (2025-003)

Material Weakness 2025

CITY OF LICKING

MO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Cash Management

The City agrees with the finding and will implement the following: (1) develop written policies and procedures to ensure compliance with Uniform Guidance (2 CFR 200), (2) formally adopt the policies and procedures, and (3) distribute policies and train staff on the new procudures.

View Audit 402340

Finding 1215686 (2025-002)

Material Weakness 2025

Renton School District No. 403

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

To address this issue and strengthen compliance controls, the District has implemented and will continue the following corrective actions: 1. Standardized Time-and-Effort Procedures The District has revised and standardized procedures for collecting, reviewing, and retaining time-and-effort document...

To address this issue and strengthen compliance controls, the District has implemented and will continue the following corrective actions: 1. Standardized Time-and-Effort Procedures The District has revised and standardized procedures for collecting, reviewing, and retaining time-and-effort documentation for all federally funded employees and substitutes charged to Title I and other federal programs. 2. Training and Guidance District staff responsible for payroll processing, federal program oversight, and school-level administration will receive annual training regarding federal time-andeffort requirements, including requirements for semiannual certifications, personnel activity reports, signature and date requirements, and retention expectations. 3. Centralized Monitoring and Review The District has updated its centralized review process to verify that all required timeand- effort documentation is completed accurately and retained timely before payroll expenditures are finalized and charged to federal programs. This review includes periodic monitoring by Business Services and Program staff. 4. Tracking and Documentation Controls The District is updating its tracking mechanisms, including standardized forms, submission deadlines, and periodic compliance checklists, to ensure required certifications are collected and retained for all applicable employees each reporting period. 5. Ongoing Compliance Monitoring District management will conduct periodic internal reviews of federally funded payroll documentation throughout the fiscal year to ensure continued compliance and to promptly address any deficiencies identified. The District expects these corrective actions to strengthen internal controls and ensure ongoing compliance with federal and OSPI requirements for time-and-effort documentation.

View Audit 402334

Finding 1215621 (2025-004)

Material Weakness 2025

The Montrose Center

TX

Reporting Allowable Costs / Cost Principles HUD Housing Programs

Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS00013050...

Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS000130500013, Contract Year: 09/01/24-08/31/25; Prevention and Behavioral Health Promotion Youth Prevention Services, Contract Number: HHS001344700032, Contract Year: 09/01/24-08/31/25. Condition and context: During our testing of the Federal Financial Reports, we noted that the final financial status reports were submitted late and the reports did not have evidence of review and approval. Additionally, a recoupment of $33,541 was required by the funder upon review of the closeout report for contract number HHS000130500013. Recommendation: Re-emphasize policies and procedures to meet the grant reporting requirements and ensure that all reports are independently reviewed prior to submission. Planned corrective action: Management will maintain a grant reporting deliverables calendar covering all federal and state reporting requirements, with internal due dates set in advance of funder deadlines and assigned to a specific grant manager. No Federal Financial Report or closeout report will be submitted without documented independent review and approval by the Controller, with preparer, reviewer, and approver sign-off retained in the grant file alongside the supporting reconciliation to the CYMA general ledger. Responsible officer: Michael McIntyre, Chief Administrative Officer. Estimated completion date: August 31, 2026.

View Audit 402329

Finding 1215568 (2025-005)

Material Weakness 2025

Red Cloud Indian School, Inc.

SD

Allowable Costs / Cost Principles § 200.303

Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the...

Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the underlying direct costs for the award for the fiscal year ended June 30, 2025. Corrective Action Plan: Approved indirect costs on federal grants will be drawn down in the same fiscal year that the direct costs were incurred. If the draw down is not completed by the end of the fiscal year, a receivable will be recorded in the financial statements. Responsible Individuals: Andrea Eagle Bull, VP for Finance and John Hussman, Grants Manager Anticipated Completion Date: July 2026

View Audit 402247

Finding 1215566 (2025-003)

Material Weakness 2025

Change Happens!

TX

Allowable Costs / Cost Principles Period of Performance HUD Housing Programs

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-0...

Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. Planned corrective action: Management has implemented strengthened procedures related to payroll allocations, grant coding, allowable costs review, and monitoring of grant periods of performance. Corrective actions include: 1) Enhanced review procedures to ensure expenditures are charged to the appropriate funding source and grant period. 2) Review of payroll allocations against approved grant budgets and supporting time and effort certifications where applicable. 3) Monthly review meetings between finance personnel and program leadership to review coding accuracy, budget status, payroll allocations, and grant compliance requirements. 4) Additional staff training related to Uniform Guidance cost principles, allowable costs, grant periods of performance, and GAAP financial reporting requirements. 5) Improved grant expenditure tracking and monitoring procedures to identify coding errors or compliance concerns timely. 6) Strengthened documentation retention procedures to ensure expenditures are properly supported and audit ready. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

View Audit 402238

Finding 1215565 (2025-002)

Material Weakness 2025

Change Happens!

TX

Allowable Costs / Cost Principles Cash Management Reporting

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/2...

Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Recommendation: Same as finding reported as #2025-001. Planned corrective action: Management has implemented enhanced grant reimbursement and compliance procedures designed to strengthen oversight, documentation standards, and review procedures. Corrective actions include: 1) Implementation of a formal grant reimbursement and drawdown review process requiring complete supporting documentation prior to submission. 2) Required supporting documentation now includes invoices, proof of payment, payroll documentation, time and effort certifications where applicable, budget verification, and grant period review. 3) All federal reimbursement requests require independent review and approval by the Chief Executive Officer prior to submission to ensure compliance with grant terms and conditions, Uniform Guidance requirements, federal regulations, and GAAP reporting standards. 4) Monthly grant compliance meetings are conducted to review reimbursement activity, grant expenditures, reporting deadlines, allowable costs, and budget variances. 5) Program and finance staff are participating in ongoing grant compliance training related to federal regulations, grant-specific requirements, documentation standards, allowable costs, and financial management procedures. Training efforts include periodic reviews and testing where applicable to reinforce compliance expectations. 6) Implementation of standardized grant tracking and reimbursement monitoring procedures to improve accountability and strengthen oversight. 7) Periodic internal compliance reviews of grant files, reimbursement requests, and supporting documentation to identify and address deficiencies proactively. Responsible officer: Anita Bates, Chief Executive Officer Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.

View Audit 402238

Finding 1215561 (2025-004)

Material Weakness 2025

General John J Pershing Memorial Hospital Association

MO

Cash Management Procurement, Suspension & Debarment Subrecipient Monitoring § 200.305

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen it...

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen its federal grant cash management procedures and will perform and document cost verification prior to all federal grant drawdowns beginning in fiscal year 2026.

View Audit 402223

Finding 1215556 (2025-001)

Material Weakness 2025

Nexus Recovery Center Inc.

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Reporting

Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of ...

Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of established approval procedures, as 2 of the 25 sampled credit card transactions charged to the grant did not include documented supervisory approval prior to payment. However, compensating controls existed, including Finance Department review of all expenditures prior to payment of the Brex account and additional review of expenses charged to the grant during preparation of monthly grant invoices and reporting. No unallowable costs or, questioned costs, were identified. To remediate the finding, all supervisors have received additional training and reminders regarding requirements for timely review and approval of expenditures prior to payment processing. In addition, the accounting team has implemented procedures prohibiting payment processing until all required approvals have been completed and documented. Management believes these enhanced controls strengthen adherence to existing policies and reduce the likelihood of recurrence. Management notes that the supervisor associated with the exceptions is no longer employed by the Organization; however, corrective actions focus on strengthening processes and controls rather than reliance on personnel changes. Corrective Action Planned/Implemented: • Refresher training provided to supervisors regarding expenditure review and approval requirements. • Accounting procedures updated to prevent payment processing prior to completion and documentation of all required approvals. • Existing accounting department monitoring procedures will continue, including review of expenditures before payment and grant expenditure review during monthly reporting. Responsible Party: Controller / Accounting Department Implementation Date: Implemented as of April 2026

View Audit 402221

Finding 1215545 (2025-001)

Material Weakness 2025

La Center School District

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE La Center School District No. 101 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of F...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE La Center School District No. 101 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with time and effort requirements. Name, address, and telephone of District contact person: Gary McGarvie, Business Manager PO Box 1840 La Center, WA 98629 (360) 263-2131 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). As a new Business Manager completing year-end processes for the first time, I mistakenly overlooked attaching the semi-annual Time & Effort certification forms to the timesheets for our classified staff. While the District did maintain completed timesheets for all staff throughout the year, the formal Time & Effort certification documentation was not completed as required for federal grant compliance. To correct this and prevent it from happening again, the District has since implemented a more structured process to ensure Time & Effort documents are properly completed. This includes attaching semi-annual certification forms directly to timesheets for classified staff and sending certification forms to certificated staff twice a year. This process will ensure that the dollars being spent from federal grants are being used accurately and in accordance with federal requirements. Anticipated date to complete the corrective action: This process has already been implemented and we should not have this issue happen moving forward.

View Audit 402209

Finding 1215533 (2025-002)

Material Weakness 2025

Tuerk House, Inc.

MD

Allowable Costs / Cost Principles Reporting

Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the continued deficiencies identified in the areas of time and effort reporting and supporting documentation for...

Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the continued deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs and reaffirms its commitment to achieving full compliance. To address this repeat finding, Tuerk House has implemented or is continuing to implement the following corrective actions: • Implemented a formal time and effort certification process requiring employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. • Developed a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. • Required that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. • Established a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff have been conducted, and ongoing training will continue to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Kisun Peters, Director of Finance Anticipated Completion Date – June 30, 2026

View Audit 402190

Finding 1215515 (2025-001)

Material Weakness 2025

Association of Diabetes Care & Education Specialists

IL

Allowable Costs / Cost Principles Significant Deficiency

Delivering Evidence-Led inTerventions in Arkansas to Advance Healthy Equity and Access in Diabetes Care (DELTA AHEAD) Recommendation: We recommend the Organization review its policies and procedures during the check signing process to ensure all approvals are obtained as required by the Organization...

Delivering Evidence-Led inTerventions in Arkansas to Advance Healthy Equity and Access in Diabetes Care (DELTA AHEAD) Recommendation: We recommend the Organization review its policies and procedures during the check signing process to ensure all approvals are obtained as required by the Organization's internal control policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Accounting staff will review the policies, procedures, and workflow with ADCES and grant-focused staff to ensure there is a common understanding across the organization. Name of the contact person responsible for corrective action: Matthew Biecker, Chief Financial Officer Planned completion date for corrective action plan: Immediately

View Audit 402177

Finding 1215463 (2025-006)

Material Weakness 2025

Delta Research and Educational Foundation

DC

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking § 200.430

Views of Responsible Officials: All the Foundation's employees now complete an excel timesheet that is then submitted to their supervisor for review and approval. Payroll is processed only after all employee timesheets are approved and received by the Senior Accountant who processes payroll.

View Audit 402102

Finding 1215451 (2025-002)

Material Weakness 2025

Charles Drew Health Center, Inc.

NE

Allowable Costs / Cost Principles § 200.430

Allowable Costs/Cost Principles Finding Summary: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payrol...

Allowable Costs/Cost Principles Finding Summary: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Procedures were in progress towards the end of the current year. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained. Anticipated Completion Date: August 2026

View Audit 402069

Finding 1215439 (2025-001)

Material Weakness 2025

New York Blood Center, Inc.

NY

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.430

Blood Diseases and Resources Research (ALN 93.839) Recommendation: We recommend that the Organization reviews their calculations around payroll costs before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit...

Blood Diseases and Resources Research (ALN 93.839) Recommendation: We recommend that the Organization reviews their calculations around payroll costs before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of implementing an upgraded grants payroll allocation costs software (Paas 2.0) that contains system controls that will detect payroll changes and automatically update, thus preventing such errors in the future. In addition to these automated software controls, management will implement review procedures in parallel as a secondary measure of control to detect and prevent such errors. Management anticipates the implementation and completion of the software project and related procedures in July 2026. Name of the contact person responsible for corrective action: Mahtab Khan Planned completion date for corrective action plan: July 2026

View Audit 402060

Finding 1215405 (2025-003)

Material Weakness 2025

Association House of Chicago

IL

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

MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, ...

MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable and properly allocated, reasonably reflect the total activity for which the employee is compensated and support the distribution of the employee’s wages among specific activities or cost objectives if the employee woks on more than one federally funded program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As corrective action, management implemented a new system to track time and effort effective July 1, 2025, using the Forms Assembly platform for federally funded DHS programs. For other grants, the Agency has continued to maintain supporting time and effort documentation through Excel-based records. Management recognizes that the implementation of the Forms Assembly system has presented operational challenges, particularly due to the need to reconcile information separately with the payroll system. As a result, since October 2025, management has been evaluating and vetting alternative systems that can fully integrate time and effort reporting with payroll processing. Beginning in fiscal year 2027, the Agency plans to implement a new integrated software solution that will record employee time, grant allocations, and payroll information within a single system integrated directly with payroll processing. Management believes this integrated approach will strengthen internal controls, improve the accuracy and timeliness of reporting, reduce manual reconciliation processes, and enhance compliance with federal time and effort requirements. Name of contact person responsible for corrective action: Margarita Rosas, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026

View Audit 401983

Finding 1215393 (2025-002)

Material Weakness 2025

Council of Spanish Speaking Organizations, Inc.

PA

Allowable Costs / Cost Principles Student Financial Aid Material Weakness

Material Weakness in Internal Control over Compliance and Compliance - Allowable Costs Condition: During our testing of allowable costs, we identified IT-related expenses totaling $111,669 that were charged to the major program for services that were not performed by the vendor and for which the ent...

Material Weakness in Internal Control over Compliance and Compliance - Allowable Costs Condition: During our testing of allowable costs, we identified IT-related expenses totaling $111,669 that were charged to the major program for services that were not performed by the vendor and for which the entity did not receive any benefit. These costs were subsequently reimbursed to Concilio by the funder. Recommendation: We recommend that management strengthen internal controls over vendor payments and grant billings to ensure that only costs for services actually rendered and properly supported are charged to federal awards. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has initiated corrective actions to strengthen internal controls over vendor payments, procurement, and grant billing processes. Upon discovery of the issue, management reviewed the affected transactions and ensured reimbursement of the questioned costs to the funding agency. Procedures have been enhanced to require appropriate documentation and supervisory approval confirming that services are properly rendered prior to payment and charging of costs against awards. In addition, management has strengthened vendor oversight and contract monitoring processes, including improved verification of invoices against contractual deliverables and supporting documentation. The Compliance functions have been enhanced to include periodic reviews of program expenditures, and additional staff training will be provided on allowable cost requirements, compliance standards, and documentation expectations to prevent recurrence of similar issues. Name of the contact person responsible for corrective action: Asif Mehmood, Chief Financial Officer asif.mehmood@elconcilio.net (215)627-3100 Planned completion date for the corrective action plan: June 30, 2026

View Audit 401940

Finding 1215390 (2025-001)

Material Weakness 2025

Council of Spanish Speaking Organizations, Inc.

PA

Allowable Costs / Cost Principles Student Financial Aid Subrecipient Monitoring

Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services...

Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 60 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 43 CUA Safety Assessments, (b) 38 CUA Safety Plans, (c) 15 CUA PA Model Risk Assessments, (d) 8 CUA Documented Client Visits (Structure Case Notes), (e) 21 FAST Family Advocacy Forms, (f) 21 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 15 School Aged Report Cards, (h) 23 CUA Authorization to Release Information, (i) 12 CUA Immunizations, (j) 22 DHS Court Order Sheets, (k) 11 Child’s Photo, (l) 9 Initial CUA Single Case Plan, (m) 11 6-Month Updates to CUA Single Case Plan, (n) 2 Initial CUA Case Service Conference Summary Report, and (o) 2 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 23 DHS Service Authorization Forms, (b) 25 DHS CUA Provider Referral Forms, and (c) 20 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Enhancement of the Quality Assurance Department to strengthen oversight, monitoring activities, and internal review processes across programmatic and administrative functions. 3. Implementation of monthly reviews of client files and supporting documentation to ensure accuracy, completeness, and compliance with contractual and funding requirements. 4. Provision of enhanced staff training focused on the review of audit findings, identification of control deficiencies, and timely implementation of corrective actions. Name of the contact person responsible for corrective action: Asif Mehmood, Chief Financial Officer asif.mehmood@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2026

View Audit 401940

Corrective Action Plans

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