Corrective Action Plans

Finding 1164330 (2023-001)

Material Weakness 2023

JXN Water

MS

Internal Control / Segregation of Duties

JXN Water, Inc. hired Horne LLP to assist with grant management in May 2024. Additionally, EPA instituted new procedures in March 2024, requiring all grant funded invoices be submitted and approved by EPA prior to releasing funds from the two grants. Going forward JXN Water, Inc. is looking to hire ...

JXN Water, Inc. hired Horne LLP to assist with grant management in May 2024. Additionally, EPA instituted new procedures in March 2024, requiring all grant funded invoices be submitted and approved by EPA prior to releasing funds from the two grants. Going forward JXN Water, Inc. is looking to hire a construction contract manager to review and approve all construction related invoices prior to payment. Non construction invoices will be approved by the JXN Water, Inc. Administrative Manager prior to payment in BILL.COM. These changes should be in place by December 31, 2024.

View Audit 373772

Finding 1164324 (2023-005)

Material Weakness 2023

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties

Subsequent to year-end, the District’s Board approved a written policy on internal controls over grant funds.

View Audit 373746

Finding 1164322 (2023-003)

Material Weakness 2023

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties HUD Housing Programs

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursement...

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursements, interim financial reports, summary of cash and certificates of deposits held, and contract pay applications and construction project status as presented by the project engineer for review and approval by the Board.

View Audit 373746

Finding 1164298 (2023-002)

Material Weakness 2023

Commonwealth Utilities Corporation

MP

Reporting Internal Control / Segregation of Duties § 200.328

Person Responsible: Fiscal Administrator (Grants and Budget) Deadline: CUC agrees to develop and create a more refined tracking system and staffing for compliance purposes. A tracking system is in place as of this writing.

View Audit 373671

Finding 1164261 (2023-010)

Material Weakness 2023

Bristlecone Family Resources

CA

Eligibility Material Weakness Reporting

Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025

View Audit 373603

Finding 1163470 (2023-003)

Material Weakness 2023

Pohnpei Utilities Corporation

FM

Special Tests & Provisions HUD Housing Programs Reporting

PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO

View Audit 373080

Finding 1163399 (2023-004)

Material Weakness 2023

CUMAC/ECHO, Inc.

NJ

Internal Control / Segregation of Duties Reporting

Finding --- The Organization did not submit its Single Audit reporting package, Including the data collection form (Form SF-SAC), to the Federal Audit Clearinghouse within the required timeframe following the end of the fiscal year. The report was not filed and therefore not made available to users ...

Finding --- The Organization did not submit its Single Audit reporting package, Including the data collection form (Form SF-SAC), to the Federal Audit Clearinghouse within the required timeframe following the end of the fiscal year. The report was not filed and therefore not made available to users timely. Corrective action – The Organization will seek to achieve a timelier closing process and audit submission. 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 372936

Finding 1163397 (2023-002)

Material Weakness 2023

CUMAC/ECHO, Inc.

NJ

Internal Control / Segregation of Duties

Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action – Management understands the risk involved and will update policies and procedures to clearly define and create segregation of duties. Status --- Corrective action in progress. Completion d...

Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action – Management understands the risk involved and will update policies and procedures to clearly define and create segregation of duties. 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 07

View Audit 372936

Finding 1163319 (2023-004)

Material Weakness 2023

Abilities Network, Inc.

MD

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.

View Audit 372833

Finding 1163294 (2023-005)

Material Weakness 2023

First Nations Community Healthsource, Inc.

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal...

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal controls to guarantee the timely preparation and accurate submission of reports and records for audit purposes, particularly in alignment with the requirements outlined in 2 CFR 200.512. To effectively implement these internal controls, management will enforce procedures for the timely preparation of all necessary reports and records, including the Schedule of Expenditures of Federal Awards (SEFA). This will not only facilitate smoother audit processes but also ensure adherence to the 2 CFR 200.512. Management will train staff and establish timelines and responsibilities for report preparation and documentation to enhance compliance and streamline overall operations. Expected Outcome: -On-time Single Audit filings in compliance with federal rules. -Clear visibility and accountability for deadlines. -Reduced risk of penalties and funding delays. -Greater confidence from agencies and stakeholders. Due Date of Completion: 3 days following issuance of the audit report Responsible Party(ies): CEO, CFO

View Audit 372817

Finding 1163089 (2023-002)

Material Weakness 2023

J-TECH INSTITUTE, INC.

CA

Allowable Costs / Cost Principles Material Weakness Reporting § 200.512

Audit Finding: Finding 2023-002: 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 2023-002: 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 372663

Finding 1162983 (2023-002)

Material Weakness 2023

SACRAMENTO ASIAN PACIFIC CHAMBER OF COMMERCE

CA

Reporting Internal Control / Segregation of Duties § 200.510

Finding: 2023-002: Revised Schedule of Expenditures of Federal Awards (SEFA) Description of Finding: Expenditures reported on the SEFA required revision during the Single Audit due to some inaccuracies, including one omitted program, which occurred because review and reconciliation procedures were n...

Finding: 2023-002: Revised Schedule of Expenditures of Federal Awards (SEFA) Description of Finding: Expenditures reported on the SEFA required revision during the Single Audit due to some inaccuracies, including one omitted program, which occurred because review and reconciliation procedures were not fully sufficient. Cause: The underlying cause was insufficient internal controls over grant documentation review and the accounting of federal award activity. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian acknowledges the significance of this finding and the potential for noncompliance with Uniform Guidance with the grantors and Federal entities, as well as potential increased risk of omitted federal programs and incorrect major program determination. To remediate these issues, SacAsian will strengthen its internal controls over SEFA preparation by implementing a multi-layer review and reconciliation process. SEFA schedules will be prepared by the Director of Finance and reviewed by the newly engaged external CFO firm. Final review will be performed by the President & CEO. SacAsian will implement a more rigorous review of all grant agreements, including pass-through awards, to verify federal components and Assistance Listing Number (ALN) details to ensure all federally funded activity is fully identified and properly reported on the SEFA. The SEFA will be reconciled to the general ledger, federal award agreements, billings submitted, and other supporting documentation. In addition, directors overseeing federal programs will be required to confirm that all federal awards under their purview are completely and accurately reflected. These enhanced controls will be implemented for the 2024 audit and maintained for subsequent audit periods. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: December 2025

View Audit 372580

Finding 1162975 (2023-003)

Material Weakness 2023

The Multi-Assistance Center at Morgan's Wonderland

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Eligibility § 200.512

Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps...

Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps to strengthen oversight and ensure future compliance. Knowledgeable personnel are now in place and have been made fully aware of all federal reporting requirements and deadlines. Management is actively developing formalized policies and procedures governing federal reporting, including a centralized compliance calendar, documented workflows, defined roles and responsibilities, and an internal review process prior to submission. These measures will be implemented by the first quarter of 2026.

View Audit 372574

Finding 1162833 (2023-001)

Material Weakness 2023

United Somali Women of Maine

ME

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking

The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With...

The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. These changes were necessary to ensure proper U.S. GAAP practices were in place. These updates include accurately accruing accounts payable and accounts receivable, to ensure revenue and expenses are recognized in the proper period. We have also implemented a proper review process of the financial statements and any adjustments that are required to finalize them. The Organization believes it have fully addressed and corrected all procedures that led to this finding.

View Audit 372500

Finding 1162597 (2023-005)

Material Weakness 2023

JEWISH FAMILY SERVICES OF GREENWICH

CT

Reporting Internal Control / Segregation of Duties

Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accountin...

Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accounting function. The basic financial statements were delayed, and this caused the Single Audit for December 31, 2023, reporting deadline to be delayed. Corrective Actions We put in place an internal finance team, a CFO, an Accountant and a Consultant to operate effectively and to meet reporting deadlines. Responsible Official: Renee Carroll, CFO Implementation Date: August 14, 2025

View Audit 372284

Finding 1162595 (2023-004)

Material Weakness 2023

JEWISH FAMILY SERVICES OF GREENWICH

CT

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties § 200.300

Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review a...

Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review and note interpreter use. 3. File Accountability – Physical files labeled with responsible case manager; cross-checked during audits. 4. Compliance Reviews – Compliance Coordinator conducts quarterly file audits. Responsible Official: Javid Siddiqi, Director of Immigration Services Implementation Date: Completed January 2025; quarterly monitoring ongoing.

View Audit 372284

Finding 1162594 (2023-003)

Material Weakness 2023

JEWISH FAMILY SERVICES OF GREENWICH

CT

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.348

Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepare...

Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepared by Compliance Coordinator, then sequentially reviewed by Director of Immigration Services and CEO. 3. Submission Log – Central log with due dates, submission confirmations, and file-format checks. 4. Quarterly Spot-Checks – Compliance Coordinator tests report files on recipient software. Responsible Officials: Javid Siddiqi (Director), Rachel Kornfeld (CEO) Implementation Date: Process in place since August 2023.

View Audit 372284

Finding 1162593 (2023-002)

Material Weakness 2023

JEWISH FAMILY SERVICES OF GREENWICH

CT

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

Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant a...

Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant allocation fields (configuration underway). 2. Manager Review Cycle – Monthly allocation reports auto-sent to managers; signed approvals returned to Accounting. 3. CFO Review & Sign-off – CFO verifies and finalizes allocations before posting to FundEZ. 4. Written Policies – Comprehensive timekeeping and allocation manual (draft completed; final issue by July 15 2025). Responsible Official: Renee Carroll, CFO Target Completion: System live and policies finalized by July 30, 2025.

View Audit 372284

Finding 1162592 (2023-001)

Material Weakness 2023

JEWISH FAMILY SERVICES OF GREENWICH

CT

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.302

Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing ...

Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing finance capacity and procedures. Corrective Actions 1. Finance Team Expansion – Hired full-time CFO, staff accountant, and external consultant (Jan 2025). 2. Policy & Procedure Overhaul – New written procedures (completed Mar 2025) referencing 2 CFR 200 Subpart E. 3. Tri-System Documentation – All expenses now recorded and cross-referenced in FundEZ (accounting), Apricot (program), and a reconciliation workbook. 4. Monthly Reconciliations – Accounting staff prepare grant-by-grant reconciliations; Program Director and CFO jointly sign off during month-end close. Responsible Official: Renee Carroll, CFO Implementation Date: Fully operational as of January 2025; monthly review ongoing.

View Audit 372284

Finding 1162403 (2023-002)

Material Weakness 2023

Avita Health System

OH

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...

Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023

View Audit 372185

Finding 1162216 (2023-001)

Material Weakness 2023

Northeast Iowa Workforce Development Board

IA

Cash Management Equipment & Real Property Management Internal Control / Segregation of Duties

We will review policies and procedures for disbursements to ensure that all payments have an evidenced independent review prior to payment. We plan to implement these changes January 1, 2026.

View Audit 372029

Finding 1162186 (2023-004)

Material Weakness 2023

Tippecanoe And Chapman Lakes Regional Sewer District

IN

Subrecipient Monitoring Material Weakness Reporting

FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audi...

FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Noncompliance Condition: The District did not have proper controls in place to ensure that the RD442-2 and RD 442-3 forms were filled out and submitted. Context: Form RD442-2 and Form RD442-3 were not submitted to the granting agency. The District may submit the financial data in other forms, however, the required reporting information was not submitted at all for the year under audit. The forms are required to be submitted on GAAP accrual basis. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will prepare the required forms which will be reviewed by the Board of Directors prior to submission. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect with the next required submission for 2025.

View Audit 371994

Finding 1162000 (2023-001)

Material Weakness 2023

Pierre Indian Learning Center

SD

Internal Control / Segregation of Duties Material Weakness Reporting § 200.512

Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.

View Audit 371860

Finding 1161911 (2023-001)

Material Weakness 2023

Glens Falls Housing Authority

NY

Reporting Internal Control / Segregation of Duties

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through our March 31, 2024 and March 31, 2025 fiscal year ends. We continue to make every effort to get our filings up to date by our March 31, 2025 year end due date of...

CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through our March 31, 2024 and March 31, 2025 fiscal year ends. We continue to make every effort to get our filings up to date by our March 31, 2025 year end due date of December 31, 2025.

View Audit 371800

Finding 1161859 (2023-004)

Material Weakness 2023

Merrill Pioneer Community Hospital, Inc

IA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

We will work to establish written procedures and policies related to the management of Federal awards, including reporting requirements.

View Audit 371778

Corrective Action Plans

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