Corrective Action Plans

Finding 1160124 (2024-001)

Material Weakness 2024

WA

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

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mou...

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: The district concurs with the finding and has taken corrective action. The employee referenced in the findings is no longer employed by the district. Throughout the months-long investigation performed by OSPI, the district worked to implement changes in our internal controls to ensure strong oversight of Migrant Education Program (MEP) grant compliance, including the eligibility determination process. Changes to internal controls include: • A monthly audit of the families who were visited that month. • A trained program recruiter will conduct the eligibility interviews and home visits. • Recruiter will work with regional trained recruiter for support. • A spot check audit of students determined to be eligible district program director. • Monthly logs from staff identifying students they worked with and services provided. • Monthly meetings between MEP district director and MEP regional program manager to ensure ongoing grant compliance. • Monthly meetings with MEP Parent Advisory Committee for ongoing feedback of services provided. • Appropriate staff including the program director are required to attend Migrant grant training provided by OSPI. We thank OSPI and the Washington State Auditor’s Office for their work and collaboration. We will continue regular monitoring of the Migrant Education Program in the Mount Vernon School district to ensure compliance with all program requirements and only eligible students are being served. Anticipated date to complete the corrective action: August 31, 2025

View Audit 370525

Finding 1160043 (2024-001)

Material Weakness 2024

Gulf Coast Transit District

TX

Allowable Costs / Cost Principles Cash Management

Finding Number: 2024‐001 Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District ...

Finding Number: 2024‐001 Federal Program Name: Federal Transit Cluster Assistance Listing Numbers: 20.507, 20.526 State Program Names: State Urbanized Area Formula Program; State Formula Grants for Rural Areas Contact Person: Ted Ross, Executive Director Updated Corrective Action Plan: The District continues to strengthen its grant management framework through policy development and improved procedures. Actions to include: Improved documentation of grant expense allocation Updated purchasing procedures consistent with federal and state compliance expectations Enhanced tracking of expenditures to specific programs and funding streams These measures have been incorporated into the district’s comprehensive Finance and Administration Policy, with staff training to be ongoing. Certification The Gulf Coast Transit District affirms that all corrective actions noted above are actively corrected or are being addressed. Additional documentation or clarification will be provided to auditors upon request.

View Audit 370494

Finding 1160040 (2024-002)

Material Weakness 2024

Strasburg-Franklin Local School District

OH

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

The District will review the process for identifying and reporting federal expenditures on the SEFA.

View Audit 370491

Finding 1159894 (2024-002)

Material Weakness 2024

City of Nashua

NH

Questioned Costs Period of Performance Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Correcti...

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Corrective Action: The Nashua School District acknowledges the finding related to the control over the period of performance for federal awards (Finding 2024-002). In response, the district will develop and implement a formal internal procedure to ensure that all purchases funded by federal awards are both placed and received within the established period of performance. This procedure will include appropriate review, documentation, and oversight to maintain compliance with federal grant regulations. To further strengthen internal controls, the Nashua School District will implement a procedure limiting purchases to occur no later than 15 days prior to the grant’s end date. Additionally, all necessary services must be received and completed prior to the expiration of the grant period. Mario Andrade Krystal De Gray Superintendent Chief Operating Officer

View Audit 370436 Questioned Costs: $1

Finding 1159877 (2024-002)

Material Weakness 2024

Lubbock County Hospital District D/b/a University Medical Center

TX

Questioned Costs Allowable Costs / Cost Principles

Finding 2024-002 Information on the federal program: Federal Program Name: Mental and Behavioral Health Education and Training Grants Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.732 Award Year: January 1, 2024 to December 31, 2024 Crite...

Finding 2024-002 Information on the federal program: Federal Program Name: Mental and Behavioral Health Education and Training Grants Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.732 Award Year: January 1, 2024 to December 31, 2024 Criteria or Specific Requirement: Activities Allowed/Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) Condition: The District should only charge and be reimbursed by the grant for allowable expenditures based on the grant agreement. Correction Action Planned: We were using verbal guidance around meals, specifically page 84 of HHS Grants Policy Statement which states as follows under Consumer/ Provider Board Participation: “Allowable in accordance with applicable program regulations. When not specifically authorized by program regulations, only the following costs are allowable with OPDIV prior approval: The reasonable costs of necessary meals furnished by the recipient to consumer or provider participants during scheduled meetings if not reimbursed to participants as per diem or otherwise.” The conference in question was held outside some participants shift time so light refreshments were provided. However, in order to ensure compliance with the Notice of Award Terms and Conditions Grant Specific Term #5, the University Medical Center will not submit unallowable meal costs and provide refresher for existing grant Program Managers to ensure they understand the terms and conditions to avoid unallowable costs and discuss the terms and conditions with the HRSA Grants Management Specialist and Project Officer if questions arise. Contact Person (s) Responsible for Corrective Action: Aaron Davis, VP & Chief Experience Officer Anticipated Completion Date: The Corrective Action will be implemented by October 31, 2025 in response to the auditors’ recommendation.

View Audit 370418 Questioned Costs: $1

Finding 1159861 (2024-007)

Material Weakness 2024

Opportunities Credit Union

VT

Allowable Costs / Cost Principles HUD Housing Programs Internal Control / Segregation of Duties

Management acknowledges the oversight and agrees with the recommendation. At the time of the finding, the Credit Union had not established written policies and procedures specific to the administration of the CDFI ERP program, which was required under the grant agreement. However, this finding relat...

Management acknowledges the oversight and agrees with the recommendation. At the time of the finding, the Credit Union had not established written policies and procedures specific to the administration of the CDFI ERP program, which was required under the grant agreement. However, this finding relates to the pre-merger entity’s administration of the CDFI ERP program. Since the merger, the current Credit Union is no longer a member of the CDFI Fund and therefore does not participate in federal programs subject to these requirements. Accordingly, the development of written policies and procedures related to federal grant administration is no longer applicable. To address the finding: • The issue has been documented as part of merger due diligence. • Management has confirmed that no further actions are required, as the current Credit Union does not administer CDFI or federal grant programs. CU1 will prepare adequate policies and procedures if it becomes applicable in the future. Expected Completion Date – Completed Responsible Parties – Wendy Gorevan, CFO (FAFCU pre-merger) and Scott McDonald, CFO (post-merger)

View Audit 370401

Finding 1159859 (2024-005)

Material Weakness 2024

Opportunities Credit Union

VT

Allowable Costs / Cost Principles

Management acknowledges the error and agrees with the recommendation to strengthen documentation controls. While written approval was ultimately obtained from CDFI to cover the full $412,728 in expenditures, the Credit Union recognizes that contemporaneous documentation should have been maintained p...

Management acknowledges the error and agrees with the recommendation to strengthen documentation controls. While written approval was ultimately obtained from CDFI to cover the full $412,728 in expenditures, the Credit Union recognizes that contemporaneous documentation should have been maintained prior to incurring costs above the allowable limit. It should be noted that this expenditure and related documentation issue occurred prior to the recent merger. Following the merger, the current Credit Union is no longer a member of the CDFI Fund, and therefore the CDFI ERP reporting and expenditure requirements are no longer applicable. To address the finding, CU1 has: • Obtained written approval from CDFI to retroactively authorize the full expenditures incurred. • Documented the issue and corrective steps as part of merger due diligence. As CDFI Fund membership and related restrictions no longer apply post-merger, no further corrective actions are necessary. Expected Completion Date – Completed Responsible Parties – Wendy Gorevan, CFO (FAFCU pre-merger) and Scott McDonald, CFO (post-merger)

View Audit 370401

Finding 1159800 (2024-003)

Material Weakness 2024

City of Akron, Ohio

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.

View Audit 370339 Questioned Costs: $1

Finding 1159760 (2024-001)

Material Weakness 2024

Connecticut Harm Reduction Alliance, Inc.

CT

Allowable Costs / Cost Principles Cash Management Reporting

Management will continue to request invoices from vendors in a timely manner. In the event a vendor fails to provide such invoice management will make reasonably estimate of expense to be accrued at year-end.

View Audit 370326

Finding 1159731 (2024-002)

Material Weakness 2024

Seward Association for the Advancement of Marine Science

AK

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.430

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS

View Audit 370314

Finding 1159690 (2024-003)

Material Weakness 2024

The Family Conservancy, INC

KS

Questioned Costs Allowable Costs / Cost Principles § 200.403

Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. C...

Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with Uniform Guidance requirements for indirect costs, the following actions will be implemented: 1. Establish Written Indirect Cost Procedures – Develop and document procedures to ensure indirect costs are consistently calculated at the approved de minimis rate per the federal grant award on total direct costs during the performance period. 2. Implement Pre-Posting Review – Require a supervisory review of indirect cost calculations before charges are recorded to the general ledger and before grant reimbursements are submitted. We have implemented new procedures to ensure that indirect costs are included in each invoice for reimbursement. 3. Staff Training – Provide training for grants and finance staff on indirect cost requirements, the proper application of the de minimis rate, and reconciliation processes in accordance with 2 CFR 200.414(f). 4. Quarterly Reconciliations – Implement quarterly reconciliations of indirect costs applied to grants to confirm rates are applied correctly and consistently throughout the fiscal year. 5. Continuity Controls – Assign responsibility for indirect cost oversight to both a primary and a backup staff member to ensure consistency during periods of management turnover. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • New procedures: June 15, 2025 • Written procedures in place: December 31, 2025 • Staff training completed: January 31, 2026 • Supervisory review and reconciliations implemented: Beginning with January 2026 close

View Audit 370280 Questioned Costs: $1

Finding 1159689 (2024-002)

Material Weakness 2024

The Family Conservancy, INC

KS

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Corrective Action Plan Identifying Number: 2024-002 Finding: The Agency did not verify that one particular vendor was not suspended or debarred when it entered into a contract with the vendor who received $25,000 or more in federal grant funds. Corrective Actions Taken or Planned: 1. Review of Vendo...

Corrective Action Plan Identifying Number: 2024-002 Finding: The Agency did not verify that one particular vendor was not suspended or debarred when it entered into a contract with the vendor who received $25,000 or more in federal grant funds. Corrective Actions Taken or Planned: 1. Review of Vendor Requirement Checks a formal review will be implement to review the procurement contract reviews and verification performed prior to any expenditures related to the contract are performed. 2. Training and Vendor Requirement Checks- Provide training to all procurement staff on federal grant compliance requirements, including performance and documentation of the suspension/debarment verification via SAM.gov prior to entering into a contract. 3. Ongoing Monitoring – The VP of Finance will provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Gino Taylor, Vice President of People, Culture, & Equity Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: ● Written procedures in place: September 30, 2025 ● Staff training completed: October 31, 2025 ● Audit completion: December 31, 2025

View Audit 370280

Finding 1159688 (2024-001)

Material Weakness 2024

The Family Conservancy, INC

KS

Questioned Costs Allowable Costs / Cost Principles § 200.403

Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or ...

Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with 2 CFR 200.403(e), the following actions will be implemented: 1. Establish Written Cutoff Procedures – Formal written procedures will be developed for reviewing service dates and supporting documentation prior to posting expenditures in the general ledger. These procedures will specifically address Uniform Guidance period-of-performance requirements. 2. Implement Supervisory Review – All expenditures charged to federal awards will undergo supervisory review at period-end. The review will confirm that expenses are recorded in the proper performance period before submission for reimbursement. Effective June 2025, the Vice President of Finance and the Controller performed a retrospective review of 2024 expenses to confirm that they were allocated to the correct reporting period. This supervisory review has continued into the current reporting period with no exceptions noted. 3. Staff Training – Grants and finance staff will receive focused training on Uniform Guidance cost principles, proper expenditure cutoff, and documentation standards to ensure consistent application. Staff training will include review of the finding and leadership will highlight the importance of verifying the correct reporting period for each entry. 4. Continuity Controls – To address turnover risk, responsibility for cutoff procedures will be assigned to both a primary and a backup staff member to provide coverage and reduce errors caused by staff changes. 5. Ongoing Monitoring – The VP of Finance will review quarterly grant compliance checklists and provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • Management supervisory review procedures: June 15, 2025 • Written cutoff procedures in place: December 31, 2025 • Staff training completed: January 31, 2026

View Audit 370280 Questioned Costs: $1

Finding 1159641 (2024-003)

Material Weakness 2024

Town of Dauphin Island

AL

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers ...

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers using the new due-to due-from procedures. In addition, our staff is currently researching a variety of software programs in order to strengthen our in-house grant management procedures to maintain full compliance. The Town will also consider hiring additional personnel and/or soliciting the services of a professional grant manager to further assist with future grant opportunities, particularly those involving grant funds.

View Audit 370259

Finding 1159584 (2024-001)

Material Weakness 2024

Franklin County Technical School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.

View Audit 370226 Questioned Costs: $1

Finding 1159572 (2024-002)

Material Weakness 2024

Toole County

MT

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

Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.

View Audit 370216

Finding 1159462 (2024-002)

Material Weakness 2024

City of Aledo

IL

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Period of Performance § 200.302

City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance o...

City of Aledo Program Specific Audit Recommendation 2024-001 We recommend that the Organization review the requirements of 2 CFR Section 200.302 to develop allowable cost, activity, and period of performance activities to be followed. Management Response: The organization recognizes the importance of having written policies and procedures to ensure cost are allowed and reasonable for the federal program. To address this finding, the agency has implemented the following corrective actions:  Review requirements of 2 CFR Section 200.302 as it relates to internal controls and financial management  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocation, efforts of personnel, fringe benefits and indirect charges for allowability, adherence to cost principles, accuracy, and completeness  Create documented policies and procedures that details how the grantee will review and approve invoices, cost allocations, efforts of personnel, fringe benefits and indirect charges to ensure they were incurred during the period of performance Responsible Staff: City Official Implementation Date: October 1,2025 90

View Audit 370207

Finding 1159461 (2024-005)

Material Weakness 2024

Wadena County

MN

Allowable Costs / Cost Principles Material Weakness

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will enact a process to ensure all reports are received and approved prior to the reporting deadline. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 370195

Finding 1159458 (2024-004)

Material Weakness 2024

Wadena County

MN

Eligibility Allowable Costs / Cost Principles Material Weakness

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: Ther...

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure casefiles are reviewed consistently and document that review. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 370195

Finding 1159448 (2024-003)

Material Weakness 2024

School of Excellence in Education

TX

Allowable Costs / Cost Principles Cash Management Reporting

No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage i...

No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage in the accounting system to the approved percentages in the semi-annual time and effort logs to verify accuracy. These improved internal procedures will provide proper compliance over allowable costs. Annual audit of all grant-funded employee positions at the start of each school year, reviewed by grants team, HR, and accounting to verify accuracy of all employee costing allocations to grants.

View Audit 370184

Finding 1159424 (2024-003)

Material Weakness 2024

Social & Environmental Entrepreneurs, Inc.

CA

Questioned Costs Allowable Costs / Cost Principles

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to g...

Single Audit Finding: 2024-003 Allowable Costs and Allowable Activities (Material Weakness in Internal Controls over Compliance) Condition: The auditors identified an instance of material noncompliance; for transactions sampled under ALN 21.027, timesheets did not adequately support the charges to grants. Additionally, in the transactions tested for ALN 66.615, there was no sufficient documentation to support the total fringe benefit amounts charged to the grants. Repeat Finding: Yes, similar deficiencies noted in 2023‐003. Views of Responsible Officials: There was a finding that was noted related to the tracking of personnel costs to the federally funded contract. SEE Accounting and Administration, which includes HR, has established and implemented uniform timekeeping procedures requiring all employees, both exempt and non-exempt, whose salaries are charged to federal contracts to submit accurate and complete timecards that reflect the actual hours worked. These formal procedures are monitored, reviewed, and reconciled on a monthly basis. Official Responsible for Ensuring CAP: Jennifer Hoffman, CEO; Anna Zaricki, CFO; Trevis Bird, COO; Monique Gutierrez, Sr-HRD; Arthur Doi, Controller; and Justin Yamashiro, Audit Manager are responsible for ensuring corrective action is implemented. Planned Completion Date for CAP: December 31, 2026

View Audit 370147 Questioned Costs: $1

Finding 1159410 (2024-001)

Material Weakness 2024

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting

View Audit 370132

Finding 1158306 (2024-006)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Student Financial Aid Allowable Costs / Cost Principles Reporting

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...

Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.

View Audit 370128

Finding 1158246 (2024-001)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158227 (2024-002)

Material Weakness 2024

Native Sun Community Power Development

MN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Significant Deficiency § 200.303

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...

Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025

View Audit 370119

Corrective Action Plans

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