Corrective Action Plans

Finding 1163222 (2024-007)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Allowable Costs / Cost Principles

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization follow policies and procedures put in place in regard to the approval of cash disbursements. Explanation of disagreement with audit fin...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization follow policies and procedures put in place in regard to the approval of cash disbursements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has implemented policies and provided additional training to new staff to ensure compliance. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163221 (2024-006)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Exp...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will implement policies and procedures to implement subrecipient monitoring. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31. 2025.

View Audit 372710

Finding 1163218 (2024-003)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Special Tests & Provisions

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreemen...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are reviewing our current policies and procedures in these areas to determine if any changes should be implemented. Greater Health Now has increased trainings for staff members in terms of the documentation required to purchase goods and services with grant funds. Furthermore, to strengthen our oversight of sole-source contracts awarded with program and non-program funds, we will introduce stringent measures requiring thorough documentation of the vendor’s or contractor’s qualifications. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163067 (2024-003)

Material Weakness 2024

Productive Alternatives, Inc.

MN

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The Organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should rec...

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The Organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should reconcile the budgeted payroll and benefits allocations charged to the grant after-the-fact to actual work performed to ensure the allocation was accurately reflected. The Organization should ensure expenditures are charged to proper grant year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure moving forward that proper support is retained for allowable costs charged to the grant and budgeted amounts are reconciled to after-the fact actual amounts. Name(s) of the contact person(s) responsible for corrective action: Carrie Beithon, Director of Financial Services Planned completion date for corrective action plan: 12/31/2026

View Audit 372641 Questioned Costs: $1

Finding 1163000 (2024-007)

Material Weakness 2024

New Brighton Borough

PA

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Recommendation: We recommend that the Borough strengthen its internal controls over the authorization of ARPA-funded expenditures by ensuring that all individual disbursements are reviewed and approved by the Borough Council or other designated officials prior to payment. Alternatively, if the Borou...

Recommendation: We recommend that the Borough strengthen its internal controls over the authorization of ARPA-funded expenditures by ensuring that all individual disbursements are reviewed and approved by the Borough Council or other designated officials prior to payment. Alternatively, if the Borough intends to continue approving projects on an overall basis, it should establish and document clear procedures specifying when and how individual payments within approved projects are deemed authorized. Management's Response: Management agrees that additional clarification and documentation of the approval process for ARPA-funded disbursements will strengthen internal controls and ensure transparency in the use of Federal funds. The Borough will review its current approval procedures and implement guidance specifying how individual disbursements under previously approved ARP A projects are to be authorized and documented. Where appropriate, individual payments will be presented to the Borough Council for approval prior to processing.

View Audit 372591

Finding 1162997 (2024-004)

Material Weakness 2024

New Brighton Borough

PA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

2024-4 Federal Expenditure Policies Recommendation: We recommend that the Borough develop and implement comprehensive written procurement policies and conflict of interest policies that comply with the Uniform Guidance. Management's Response: The Borough will research federal expenditure policies an...

2024-4 Federal Expenditure Policies Recommendation: We recommend that the Borough develop and implement comprehensive written procurement policies and conflict of interest policies that comply with the Uniform Guidance. Management's Response: The Borough will research federal expenditure policies and determine the best way to move forward.

View Audit 372591

Finding 1162987 (2024-001)

Material Weakness 2024

Appalachian Ohio Manufacturers Coalition

OH

Allowable Costs / Cost Principles

AOMC will retrain all staff and supervisors on the required payroll approval process. All timesheets must be reviewed and approved by the employee’s supervisor before being submitted for payroll processing. AOMC has also worked with the board to ensure that if no Executive Director is in place, a bo...

AOMC will retrain all staff and supervisors on the required payroll approval process. All timesheets must be reviewed and approved by the employee’s supervisor before being submitted for payroll processing. AOMC has also worked with the board to ensure that if no Executive Director is in place, a board member will approve timesheets or designate an AOMC employee with the authority to approve time.

View Audit 372589

Finding 1162970 (2024-003)

Material Weakness 2024

City of Saratoga Springs, New York

NY

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.412 § 200.512

The City has established policies and procedures related to grant administration and accounting guidelines for allowable costs. The City is aware of the deadline for the submission of the Single Audit. The City is taking steps to ensure that personnel have received guidance and training regarding gr...

The City has established policies and procedures related to grant administration and accounting guidelines for allowable costs. The City is aware of the deadline for the submission of the Single Audit. The City is taking steps to ensure that personnel have received guidance and training regarding grant accounting, including deadlines for the audit. Responsible Party and Anticipated Completion Date: Commissioner of Finance Minita Sanghvi 12/31/2026

View Audit 372565

Finding 1162966 (2024-003)

Material Weakness 2024

Menominee County, Wisconsin

WI

Procurement, Suspension & Debarment Allowable Costs / Cost Principles

Recommendation: CLA recommends the County complete an assessment of its financial management system and related internal controls over federal awards. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new pol...

Recommendation: CLA recommends the County complete an assessment of its financial management system and related internal controls over federal awards. This assessment should include an evaluation of existing policies and procedures to determine where additional enhancements should be made or new policies created, a plan to communicate these policies to County employees, and procedures to periodically review and update, as considered necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County worked to update necessary policy and procedures late in 2024 and continued into 2025 with additional plans to gain better understandings and training for department personnel on UGG requirements. Name(s) of the contact person(s) responsible for correction action: Kourtney Erickson Planned completion date for corrective action: December 31, 2025

View Audit 372563

Finding 1162906 (2024-008)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the education stabilization grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162896 (2024-007)

Material Weakness 2024

City of Peabody

MA

Allowable Costs / Cost Principles Eligibility Material Weakness

Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required documentation is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.

View Audit 372554

Finding 1162893 (2024-006)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the Title I grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162890 (2024-005)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the special education grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Finding 1162879 (2024-001)

Material Weakness 2024

Black Eagle Cascade County Water and Sewer District

MT

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

November 18, 2025 Re: 2024 Audit Corrective Action Plan for the Black Eagle-Cascade County Water & Sewer District BLACK EAGLE WATER AND SEWER DISTRICT CORRECTIVE ACTION PLAN Person responsible for corrective action: Sarah Peck, Water District Secretary Corrective Action: The Water District Secretary...

November 18, 2025 Re: 2024 Audit Corrective Action Plan for the Black Eagle-Cascade County Water & Sewer District BLACK EAGLE WATER AND SEWER DISTRICT CORRECTIVE ACTION PLAN Person responsible for corrective action: Sarah Peck, Water District Secretary Corrective Action: The Water District Secretary will be brought before the Board of Directors every invoice from Central, WET, Shumaker, and Administration (payroll) for a separate vote for approval. Going forward, invoices will be formally approved by the board at each meeting. Anticipated completion date: The board will formally approve past invoices at the November 18, 2025 meeting. Sarah Peck, Secretary/ Grant Manager Charles T. Harant, Chair

View Audit 372545

Finding 1162835 (2024-001)

Material Weakness 2024

The Learning Community Charter School

RI

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

2024-1 Payroll Allocations Contact Person - Shannon MacKenzie, Director of Finance Description of Corrective Action - The School’s new Director of Finance will continue to work closely with the Deputy Head of School to ensure that payroll and other expenses are being charged correctly to our grant f...

2024-1 Payroll Allocations Contact Person - Shannon MacKenzie, Director of Finance Description of Corrective Action - The School’s new Director of Finance will continue to work closely with the Deputy Head of School to ensure that payroll and other expenses are being charged correctly to our grant funding. We will ensure that the expenses for the grants are reviewed monthly and will make the correct adjustments on a timely basis to ensure that the grants are charged for the correct amounts based on the grant documents. The Director of Finance will also make sure that the time and efforts match the payrolls and that the changes in the payroll are updated on a timely basis. Completion Date - June 30, 2025 Root Cause - Turnover in the Director of Finance position

View Audit 372502 Questioned Costs: $1

Finding 1162801 (2024-002)

Material Weakness 2024

TOWN OF CHESTER

MA

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

Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town plans to draft and adopt policies. Anticipated Completion Date: 12/31/2025 Contact: Andrew Alward, Town Administrator

View Audit 372434

Finding 1162793 (2024-005)

Material Weakness 2024

Micronesian Legal Services Corporation

MP

Subrecipient Monitoring Allowable Costs / Cost Principles Significant Deficiency

Management’s Response and Corrective Action Plan: Management agrees. Responsible person: Executive Director Lee Pliscou Corrective action planned: This has been corrected as of October 2025. MLSC Board of Directors approved a revised MLSC Accounting Manual with updates intended to comply with LSC’s ...

Management’s Response and Corrective Action Plan: Management agrees. Responsible person: Executive Director Lee Pliscou Corrective action planned: This has been corrected as of October 2025. MLSC Board of Directors approved a revised MLSC Accounting Manual with updates intended to comply with LSC’s Financial Guide on cost allocation. In particular, our new cost allocation policy addresses: ● Direct and indirect cost definitions ● Direct cost allocation methodology ● Indirect cost allocation methodology including allocation bases (total direct costs) ● Frequency of allocation (annual) ● Who conducts the allocation and who performs the review (Chief Fiscal Officer, Executive Director) ● Documentation requirements to support the allocation (calculation work papers) ● Reconciliation process related to salaries and wages directly charged to LSC grants and contracts ● Methodology to address “exception for certain indirect costs.” Anticipated completion date: Completed.

View Audit 372427

Finding 1162789 (2024-001)

Material Weakness 2024

Micronesian Legal Services Corporation

MP

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

Management’s Response and Corrective Action Plan: MLSC acknowledges the finding and concurs with the auditor’s recommendation. Management is committed to maintaining accurate, timely, and reliable financial reporting in accordance with Government Auditing Standards and the LSC Financial Guide. Respo...

Management’s Response and Corrective Action Plan: MLSC acknowledges the finding and concurs with the auditor’s recommendation. Management is committed to maintaining accurate, timely, and reliable financial reporting in accordance with Government Auditing Standards and the LSC Financial Guide. Responsible person: Exec. Director, Lee Pliscou Corrective action planned: MLSC currently has a Financial Management and Internal Control Policy. This policy is strictly being enforced and fully implemented to ensure compliance with both the LSC Financial Guide and Government Auditing Standards. • MLSC has established a financial oversight and audit committee, and identifies the duties of the committee in writings. • The financial oversight and audit committee is required to review quarterly the management report prepared by the Chief Fiscal Officer. • The Chief Fiscal Officer will review and reconcile the subsidiary ledger after the month-end close and before the submission of monthly report to the Board of Directors. • To ensure that internal controls are strengthened and that future financial statements are properly prepared, the Chief Fiscal Officer will conduct an annual training with all accounting staff on reconciliation procedures before the year-end close. Anticipated completion date: Dec. 31, 2026

View Audit 372427

Finding 1162784 (2024-001)

Material Weakness 2024

Public Health Management Corporation

PA

Allowable Costs / Cost Principles § 200.403

CVCA lost key accounting staff and experienced significant difficulty in locating and hiring competent replacements within the department. New fiscal staff were onboarded in October 2024. The new fiscal staff started to enforce the proper policies and procedures starting in November 2024 when prior ...

CVCA lost key accounting staff and experienced significant difficulty in locating and hiring competent replacements within the department. New fiscal staff were onboarded in October 2024. The new fiscal staff started to enforce the proper policies and procedures starting in November 2024 when prior finance staff was no longer involved managing CVCA books. All invoices and journal entries need proper backup attached for approval and processing.

View Audit 372420

Finding 1162756 (2024-004)

Material Weakness 2024

Hope Village - Tiny Housing Alternatives, Inc.

WI

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

Finding Number: 2024-004 Failure to Identify Single Audit Requirement Views of Responsible Officials and Corrective Action: The Organization was not explicitly made aware of the Uniform Guidance requirements and mistakenly assumed that since this originated from the state, it was state funding. The ...

Finding Number: 2024-004 Failure to Identify Single Audit Requirement Views of Responsible Officials and Corrective Action: The Organization was not explicitly made aware of the Uniform Guidance requirements and mistakenly assumed that since this originated from the state, it was state funding. The Organization is aware of this situation and will create and implement a formal process to review federal and state expenditures incurred and evaluate whether there are state or federal compliance audit implications for all government grants upon signing the agreement. We will then proactively communicate this with our auditor so that plans can be made to perform the applicable compliance audit. We do not view this as an ongoing deficiency, and we deem our corrective action plan to be one that fully addresses this control deficiency. Name of Responsible Person: Mike Cohoon, Executive Director Projected Implementation Date: December, 2025

View Audit 372385

Finding 1162716 (2024-004)

Material Weakness 2024

Dreaming Out Loud, Inc.

DC

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

Views of Responsible Officials: We agree with the auditor’s findings and recommendations. Intacct allows for the automatic allocation of salaries to grants directly which provides us with much better records. ADP Workforce now will put all the appropriate approvals in place, both employee and superv...

Views of Responsible Officials: We agree with the auditor’s findings and recommendations. Intacct allows for the automatic allocation of salaries to grants directly which provides us with much better records. ADP Workforce now will put all the appropriate approvals in place, both employee and supervisor. We are discussing the right method for project-specific timesheets, but think that biweekly forms for staff to fill out are the best route. Staff would check off grant-allowable activities that they engaged in and then note the hours allocated to those activities.

View Audit 372349 Questioned Costs: $1

Finding 1162699 (2024-003)

Material Weakness 2024

Lincoln Hall

NY

Cash Management Allowable Costs / Cost Principles

Finding Number: 2024-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/23 - 06/30/24 Planned Corrective Action: The auditors noted that certain payroll expenses and other than personnel s...

Finding Number: 2024-003 Allowable Costs; Cash Management (Material Weakness) Programs: Unaccompanied Children Program ALN#93.676 Contract#: 90ZU0323 & 90ZU0548 Contract Period: 07/01/23 - 06/30/24 Planned Corrective Action: The auditors noted that certain payroll expenses and other than personnel service (OTPS) expenses are not being charged directly or allocated to the correct cost center in the accounting system monthly. Therefore, the amounts being drawn down during any given month may not be fully supported until the year-end when a reallocation of costs by function occurs. Beginning in FY 2025, personnel costs are being manually recorded to the correct cost centers in Serenic Navigator each month. Additionally, OTPS expenses have been charged directly or allocated to the appropriate cost centers on a monthly basis since January 2025. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: January 2025

View Audit 372336

Finding 1162697 (2024-001)

Material Weakness 2024

Lincoln Hall

NY

Allowable Costs / Cost Principles Material Weakness

Finding Number: 2024-001 Cost Allocations (Material Weakness) Planned Corrective Action: The auditors noted that payroll and the related personnel costs are not being charged directly or allocated to the correct cost center in the Serenic Navigator accounting system monthly. The Finance team perform...

Finding Number: 2024-001 Cost Allocations (Material Weakness) Planned Corrective Action: The auditors noted that payroll and the related personnel costs are not being charged directly or allocated to the correct cost center in the Serenic Navigator accounting system monthly. The Finance team performed manual calculations of all allocations in Excel at the end of the fiscal year to update the allocations. Beginning in FY 2025, personnel costs are being manually recorded to the correct cost centers in Serenic Navigator each month. A parallel review of employee setups in ADP, our payroll system, led to the reassignment of staff to appropriate cost centers as needed. Going forward, ADP cost center assignments will be reviewed monthly to reflect any departmental changes. These steps are expected to reduce manual adjustments, improve the accuracy of interim financials, and ensure more precise federal and program drawdowns. Person Responsible: The Executive Director and Chief Financial Officer Completion Date: July 2024

View Audit 372336

Finding 1162645 (2024-005)

Material Weakness 2024

Refuge And Restoration

MO

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

Corrective Action Plan: The Organization will implement a formalized process for the review and approval of payroll transactions, including the allocation of payroll costs to grants. We will do this by adding the proper software tools in place within our financial accounting software. This process w...

Corrective Action Plan: The Organization will implement a formalized process for the review and approval of payroll transactions, including the allocation of payroll costs to grants. We will do this by adding the proper software tools in place within our financial accounting software. This process will also involve establishing clear guidelines outlining the steps for reviewing and approving payroll transactions to ensure accuracy and compliance with grant requirements and financial processes. Designated personnel, the finance manager, will be assigned the specific responsibility of preparing payroll and the CEO will review the payroll report and sign off prior to payroll execution. This will be in the system of documented processes to track and document these approvals as well as written within the policies and procedures handbook. Anticipated Completion Date: November 30, 2025

View Audit 372308

Finding 1162626 (2024-012)

Material Weakness 2024

Mental Health Association of Columbia-Greene Counties Inc.

NY

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Finding 2024-012 – Allowable and Unallowable Costs (Material Weakness) Finding: The Organization did not have sufficient controls to ensure that the allowable and unallowable costs requirement was met due to staff turnover. Management Response: Management agrees. Corrective action plan: •Develop an ...

Finding 2024-012 – Allowable and Unallowable Costs (Material Weakness) Finding: The Organization did not have sufficient controls to ensure that the allowable and unallowable costs requirement was met due to staff turnover. Management Response: Management agrees. Corrective action plan: •Develop an allowable cost checklist for all federal programs. •Management will expand controls to ensure that they are able to demonstrate that all expenses meet their procurement policy and are allowable under the grant. •Staff training will be completed by the end of 2025, and a cost allowability checklist is now used for all expenditures charged to grants. Responsible Party: CFO Completion Date/Status: Expected to be Implemented by end of 2025; ongoing review.

View Audit 372297

Corrective Action Plans

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