Corrective Action Plans

Finding 1169111 (2022-003)

Material Weakness 2022

Juel Fairbanks Chemical Dependency Services

MN

Allowable Costs / Cost Principles Questioned Costs

2022-3 Assistance Listing 93.193 Urban Indian Health Services Name of Contact Person Responsible for Corrective Action: Michelle Kellum, Executive Director Corrective Actions Planned: The Organization will take steps to maintain support of payroll charges based on actual results including timesheets...

2022-3 Assistance Listing 93.193 Urban Indian Health Services Name of Contact Person Responsible for Corrective Action: Michelle Kellum, Executive Director Corrective Actions Planned: The Organization will take steps to maintain support of payroll charges based on actual results including timesheets indicating the amounts charged reflect actual staff time spent on the program. The Organization will also take the necessary steps to ensure that grant expenditure billing reports reflect actual program expenses supported by the general ledger and agree to actual amounts charged to the program. Anticipated Completion Date: These procedures will be implemented during the 1st quarter of 2025.

View Audit 381861

Finding 1168915 (2022-002)

Material Weakness 2022

Weld Seattle

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.514

Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization implementing a grant reimbursement approval system with three...

Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization implementing a grant reimbursement approval system with three levels of review. The controls include segregation of duties between the employee who process the data and the employees who review in order to ensure any errors are identified and remediated prior to submission to the grantor. The Staff Accountant and Shared Services team process data for reimbursement and provides the data to the Finance Manager to review and create the grant filing. Once the grant filing is prepared, the Grant Administrator reviews the grant filing and provides the completed filing to the Operations Director to review and approve prior to submission to the grantor.

View Audit 381373

Finding 1168833 (2022-004)

Material Weakness 2022

Snohomish County Food Bank Coalition

WA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303

Corrective Action: Management will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant accounting processes and major federal award program compliance requirements. Anticipated Completion Date: December 31, 2025

View Audit 381040

Finding 1168824 (2022-007)

Material Weakness 2022

Bell County

TX

Allowable Costs / Cost Principles Questioned Costs § 200.303

Condition: The District has not adopted formal controls to detect and prevent unallowable costs from being charged to grant programs. Auditor substantively tested 29 expenditures, including indirect costs, across all major programs noting that all items tested were for allowable costs. Criteria: 2 C...

Condition: The District has not adopted formal controls to detect and prevent unallowable costs from being charged to grant programs. Auditor substantively tested 29 expenditures, including indirect costs, across all major programs noting that all items tested were for allowable costs. Criteria: 2 CFR 200.303(a). Cause of Condition: Unfamiliarity with requirements stated in 2 CFR 200 of the Uniform Guidance. Effect of Condition: Effect is a state of noncompliance which may impact future grant awards or failure to identify and reject un-allowed costs charged to grant programs. Questioned Costs: none. Recommendation: Draft and adopt policies and procedures to become compliant with Uniform Guidance.Corrective Action Plan: Agency policies and procedures, including a guidance template will be clearly defined to ensure compliance with Uniform Guidance. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026

View Audit 381011

Finding 1168823 (2022-006)

Material Weakness 2022

Bell County

TX

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.302 § 200.318 § 200.319

Condition: The District has not adopted written policies or procedures regarding procurements or the determination of allowable costs in accordance with the Uniform Guidance. Criteria: 2 CFR 200.302(b)(7), 2 CFR 200.318(a), and 2 CFR 200.319(d). Cause of Condition: Unfamiliarity with requirements st...

Condition: The District has not adopted written policies or procedures regarding procurements or the determination of allowable costs in accordance with the Uniform Guidance. Criteria: 2 CFR 200.302(b)(7), 2 CFR 200.318(a), and 2 CFR 200.319(d). Cause of Condition: Unfamiliarity with requirements stated in 2 CFR 200 of the Uniform Guidance.Effect of Condition: Effect is a state of noncompliance which may impact future grant awards or failure to identify and reject un-allowed costs charged to grant programs. Questioned Costs: none. Recommendation: Draft and adopt policies and procedures to become compliant with Uniform Guidance. Corrective Action Plan: Agency policies and procedures, including a guidance template will be clearly defined to ensure compliance with Uniform Guidance. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026

View Audit 381011

Finding 1168821 (2022-004)

Material Weakness 2022

Bell County

TX

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Questioned Costs § 200.302

Condition: Support for expenditure transactions does not indicate approval from an appropriate manager with authority over the department/program. Auditor tested 57 transactions of which 17 did not include evidence of approval (excluding routine expenditures such as utility bills). Criteria: General...

Condition: Support for expenditure transactions does not indicate approval from an appropriate manager with authority over the department/program. Auditor tested 57 transactions of which 17 did not include evidence of approval (excluding routine expenditures such as utility bills). Criteria: Generally accepted control procedures and 2 CFR 200.302. Cause of Condition: Initiating procurement transactions without proper approval or failing to document that approval was obtained prior to initiating the transaction. Effect of Condition: Unapproved charges, including potential unallowable costs, may be incurred and charged to the District, including federal or state programs. Additionally, the potential exists for fraud or errors to go undiscovered and uncorrected in a timely manner. Questioned Costs: none.Recommendation: We recommend that a purchase order or purchase requisition system be devised to ensure all expenditures, including those paid for by credit cards, are approved by an appropriate manager prior to making the purchase. Corrective Action Plan: Beginning January 2026, all purchases, including credit card transactions, will require Purchase approval by the Program Manager and administration prior to purchase. A Purchase Order tracking process will be implemented in Blackbaud Financial Edge NXT by April 2026 to ensure all expenditures are properly documented. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. The Financial Procedures Manual will be created and updated by June 2026 to include revised procurement approval requirements. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 06/01/2026

View Audit 381011

Finding 1168524 (2022-002)

Material Weakness 2022

The County of Butler

MO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement wit...

U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County agrees and is developing a process to ensure reports are prepared and submitted. Name(s) of the contact person(s) responsible for corrective action: Donna Hillis, County Clerk Planned completion date for corrective action plan: December 31, 2025

View Audit 380345

Finding 1168466 (2022-004)

Material Weakness 2022

Wyola School District No. 29

MT

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one em...

Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one employee (accounts payable, payroll, balancing) and many records are not able to be located. For partial 2023-24 and 2024-25 records are now fully maintained and should be accessible for audit review. Training has been provided by the District’s Financial Consultant (payroll and accounts payable). The District Financial Consultant is reviewing payroll, processing tax and retirement payments, reviewing AP and correcting coding when necessary. The Consultant is also balancing reports and submitting monthly financial reports to the Board of Trustees.

View Audit 380260

Finding 1167402 (2022-003)

Material Weakness 2022

Compañia de Turismo de Puerto Rico

PR

Allowable Costs / Cost Principles Eligibility Questioned Costs

Views of responsible officials: Before the approval of budget and the contract petition, the Chief Financial Officer will verify if the vendors are excluded as an authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified ag...

Views of responsible officials: Before the approval of budget and the contract petition, the Chief Financial Officer will verify if the vendors are excluded as an authorized Federal contractor. The Company will establish a formal procedure to ensure that all vendors for federal funds are verified against the excluded list at least once a year. This verification process will ensure compliance with federal regulations and avoid engaging with vendors who may be suspended or debarred. Additionally, this procedure will be recommended to be included in the review process for quotes or bidding requirements, further enhancing the Company’s ability to comply with federal regulations and maintain responsible vendor relationships.

View Audit 378469

Finding 1167142 (2022-002)

Material Weakness 2022

Pulaski Memorial Hospital

IN

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed as soon as possible

View Audit 378192

Finding 1166291 (2022-005)

Material Weakness 2022

Rehoboth McKinley Christian Health Care Services, Inc.

NM

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.302

Management will enforce existing internal control procedures and train staff to maintain appropriate documentation.

View Audit 377383

Finding 1166168 (2022-003)

Material Weakness 2022

City of Watertown

MA

Allowable Costs / Cost Principles Significant Deficiency

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented...

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented approval for all grant-funded purchases, and maintaining adequate supporting documentation. Time and effort reporting processes will be reinforced. Grant monitoring procedures will include periodic allowability reviews. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

View Audit 377065

Finding 1166166 (2022-002)

Material Weakness 2022

City of Watertown

MA

Allowable Costs / Cost Principles § 200.430

Re: Corrective Action Plan - Audit Finding 2022-02 - Improve Controls and Documentation over Payroll Planned Corrective Action: The District will enhance payroll documentation controls by standardizing processes for verifying pay rates, retaining payroll support documents, and documenting/approving ...

Re: Corrective Action Plan - Audit Finding 2022-02 - Improve Controls and Documentation over Payroll Planned Corrective Action: The District will enhance payroll documentation controls by standardizing processes for verifying pay rates, retaining payroll support documents, and documenting/approving transfers and allocations. Cross-department procedures between Payroll, HR, and Business Office will be formalized. Staff involved in payroll and federal grants will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

View Audit 377065

Finding 1166164 (2022-001)

Material Weakness 2022

City of Watertown

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procu...

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procurement, conflicts of interest, cash management, travel, time and effort, inventory management, and record retention. All procedures will be consolidated into a Federal Grants Procedures Manual, approved by leadership, and reviewed annually. Relevant staff will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature

View Audit 377065

Finding 1165300 (2022-003)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment § 200.318 § 200.319

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including che...

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including checklists for method of procurement, contractor selection, cost/price analysis, and justification, and will be used for all purchasing actions. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● April 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1165299 (2022-002)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs § 200.303 § 200.328 § 200.400 § 200.430

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these record...

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1164212 (2022-001)

Material Weakness 2022

County of Belknap, New Hampshire

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director

View Audit 373506

Finding 1163594 (2022-008)

Material Weakness 2022

City of Bogalusa

LA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.213 § 200.303 § 200.318 § 200.326

Material Weakness in Internal Control Over Compliance (Federal Award Program) The City will develop and implement formal written procedures for the management of Federal award expenditures and procurement activities. All fund transfers will require documented approval by authorized personnel. Procur...

Material Weakness in Internal Control Over Compliance (Federal Award Program) The City will develop and implement formal written procedures for the management of Federal award expenditures and procurement activities. All fund transfers will require documented approval by authorized personnel. Procurement processes will include verification of vendor eligibility, compliance with bid law, and retention of supporting documentation. Staff will be trained on federal compliance requirements. Responsible Party: Robert Nielson, Temporary Fiscal Administrator Timeline: December 31, 2025

View Audit 373355

Finding 1163390 (2022-003)

Material Weakness 2022

CUMAC/ECHO, Inc.

NJ

Reporting Questioned Costs Allowable Costs / Cost Principles

Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with U...

Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with Uniform Guidance and New Jersey 15-08-OMB. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07505

View Audit 372935

Finding 1163388 (2022-001)

Material Weakness 2022

CUMAC/ECHO, Inc.

NJ

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Reporting

Finding --- Inadequate controls regarding preparation of the Schedule of Expenditures of Federal Award and State Financial Assistance. Corrective action – Management will continue to enhance the internal control structure and improve the chart of accounts to maintain full transparency and implement ...

Finding --- Inadequate controls regarding preparation of the Schedule of Expenditures of Federal Award and State Financial Assistance. Corrective action – Management will continue to enhance the internal control structure and improve the chart of accounts to maintain full transparency and implement sub classes within the current software. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07505

View Audit 372935

Finding 1163271 (2022-002)

Material Weakness 2022

Serenity House of Clallam County

WA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

Significant Deficiency in Internal Control over Compliance Details: During the audit, we identified instances where we could not verify review and approval for cash and payroll disbursements were completed. Recommendation: Incorporate regular review and approval procedures on invoices, payment reque...

Significant Deficiency in Internal Control over Compliance Details: During the audit, we identified instances where we could not verify review and approval for cash and payroll disbursements were completed. Recommendation: Incorporate regular review and approval procedures on invoices, payment requests and payroll time and effort documents. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Invoices and payments are placed on an expense request form for each purchase and are to be signed by the authorization designated threshold prior to payment verified by accounts payable. • Payroll process implemented in early 2024: to double check and initial timecards with employee entries and supervisor signature, and to verify entries and sign payroll QuickBooks print out prior to check printing. This verification document is filed with the payroll timecards. Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: Feb 1 2024

View Audit 372800

Finding 1163087 (2022-002)

Material Weakness 2022

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...

Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately

View Audit 372662

Finding 1162283 (2022-008)

Material Weakness 2022

Round Valley Indian Tribes

CA

Questioned Costs Allowable Costs / Cost Principles

The Tribes, in collaboration with the Interim CFO, will review and verify indirect cost calculations to ensure accuracy and compliance with the approved indirect cost rate agreement. James Russ, Tribal Business Administrator, Wendy Wilson, Interim CFO and Sonia Horne, Grants and Contracts Accountant...

The Tribes, in collaboration with the Interim CFO, will review and verify indirect cost calculations to ensure accuracy and compliance with the approved indirect cost rate agreement. James Russ, Tribal Business Administrator, Wendy Wilson, Interim CFO and Sonia Horne, Grants and Contracts Accountant December 31, 2025

View Audit 372097 Questioned Costs: $1

Finding 1162220 (2022-002)

Material Weakness 2022

Northeast Iowa Workforce Development Board

IA

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

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the period under review, a new Title I service provider has been implemented, and multiple corrective measures have been established to strengthen eligibility determination and documentation. Eligibility checklists and sta...

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the period under review, a new Title I service provider has been implemented, and multiple corrective measures have been established to strengthen eligibility determination and documentation. Eligibility checklists and standardized enrollment packets are now required for each program. In addition, the new service provider has instituted a quality assurance process, with two directors conducting case file reviews across the local area. The NEIWDB has hired a compliance specialist to provide oversight, including ongoing, quarterly, and annual monitoring of eligibility and documentation. Title I staff utilize IowaWORKS reports and alerts to support compliance, and regular monthly technical assistance sessions, statewide trainings, and structured onboarding were provided to the new service provider. These measures were implemented beginning July 1, 2024 and are ongoing. The compliance specialist will report monitoring results to the NEIWDB to ensure accountability and corrective follow-up where needed. The Northeast Iowa Local Area believe these actions fully address the issue and will prevent recurrence in future program years.

View Audit 372030

Finding 1161447 (2022-004)

Material Weakness 2022

Medstar, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding Number: 2022-004 Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was...

Finding Number: 2022-004 Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) – healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic. Company changed payroll companies in June 2022 from Trion to DM Payroll – where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budzynowski, VP of Finance Anticipated Completion Date: 06/30/2022 - Completed

View Audit 371328 Questioned Costs: $1

Corrective Action Plans

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