Corrective Action Plans

Finding 1211143 (2022-004)

Material Weakness 2022

Carestl Health

MO

Cash Management Internal Control / Segregation of Duties § 200.305

We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to e...

We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to ensure funds are drawn and disbursed promptly ▪ Develop and enforce policies consistent with the Prompt Payment Act, including defined payment timelines ▪ Perform periodic reviews of cash flow and payment cycles to ensure compliance ▪ Assign oversight responsibility to ensure timely processing and documentation of payments Strengthening cash management practices will improve compliance with federal requirements and enhance overall financial control.

View Audit 400353

Finding 1211141 (2022-002)

Material Weakness 2022

Carestl Health

MO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...

Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations

View Audit 400353

Finding 1211140 (2022-001)

Material Weakness 2022

Carestl Health

MO

Internal Control / Segregation of Duties Cash Management Material Weakness

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.

View Audit 400353

Finding 1211101 (2022-003)

Material Weakness 2022

El Paso Alliance, Inc.

TX

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.212 § 200.318

U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the...

U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will update procurement procedures to require documented SAM.gov verification for vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Ben Bass, CEO Planned completion date for corrective action plan: May 2026

View Audit 400343

Finding 1211100 (2022-002)

Material Weakness 2022

El Paso Alliance, Inc.

TX

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.320

U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement util...

U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/services and then utilizing an approved vendors list. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will ensure the Organization follows the Procurement policy for any future acquistions over the threshold of $15,000 enumerated in the policy and obtain bids and document the selection process. Name(s) of the contact person(s) responsible for corrective action: Manuel Burrola, Accountant Planned completion date for corrective action plan: May 2026

View Audit 400343

Finding 1208815 (2022-004)

Material Weakness 2022

Sheridan Community Hospital

MI

Reporting Internal Control / Segregation of Duties § 200.512

In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of ...

In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of two years were unable to schedule annual financial audits timely. At the time when the FY 2022 single Audit was due, we had not even completed our FY2020 Audit hence the delay. Currently, the hospital is working toward getting caught up with the annual financial audits to get back on track with our policy. We just completed FY 2023 and are working on FY 2024. We hope to be done with FY 2025 and FY 2026 in the Fall of calendar year 2026.

View Audit 399700

Finding 1205802 (2022-001)

Material Weakness 2022

Reimagining Justice, Inc.

NJ

Reporting Internal Control / Segregation of Duties § 200.512

Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized o...

Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized on schedule and required reporting can be submitted before applicable deadlines. Corrective Action Plan Management acknowledges that the Single Audit reporting package and Data Collection Forms for the 2022 audit were not submitted by the required deadlines. To correct this issue and prevent recurrence, the organization has implemented the following actions:• Enhanced monitoring and tracking• Hired an internal accountant to strengthen financial oversight and reconciliation processes.• Assignment of oversight responsibility.• Staff Training.• Formalized workflows and fiscal coordination protocols with St. Joseph’s University Medical Center (fiscal sponsor) including submission timelines, approval processes, and reporting requirements.• Established external filing deadlines. Anticipated Completion Date These corrective actions were initiated in autumn 2025, and will be fully in place for the audit of the fiscal year ended September 30, 2025, ensuring timely submission by June 30, 2026. Management Statement Management believes the corrective actions implemented will ensure full compliance with federal and state reporting requirements and prevent recurrence of late audit submissions. Responsible Individual Dr. Liza Chowdhury Executive Director Date: March 17, 2026

View Audit 397546

Finding 1205534 (2022-003)

Material Weakness 2022

Kanawha Valley Collective Inc.

WV

Reporting Internal Control / Segregation of Duties § 200.512

Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Antici...

Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2026

View Audit 397204

Finding 1182847 (2022-002)

Material Weakness 2022

Prevent Child Abuse Utah

UT

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.

View Audit 394245

Finding 1182846 (2022-001)

Material Weakness 2022

Prevent Child Abuse Utah

UT

Material Weakness Internal Control / Segregation of Duties

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Ch...

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Child Abuse Utah evaluate the ongoing benefits and expenses of including this element into its system of internal control.

View Audit 394245

Finding 1182260 (2022-003)

Material Weakness 2022

Breckinridge County Fiscal Court

KY

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

Judge Lucas Response: This was an oversight on our part. Steps have been taken to fully comply with all SEFA reporting in the future.

View Audit 393643

Finding 1181984 (2022-004)

Material Weakness 2022

Community Services Office of Hot Springs and Garland County, Arkansas, Inc.

AR

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.328 § 200.329

Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a...

Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a process where a staff accountant will prepare the necessary reports and the chief financial officer will review such reports. Alternatively, if the chief financial officer must prepare such reports, the review will be performed by the executive director.

View Audit 393341

Finding 1181969 (2022-105)

Material Weakness 2022

Inter-Tribal Council of Nevada, Inc.

NV

Internal Control / Segregation of Duties

Condition and Context: The program guidelines require ITCN to verify the safety of all providers who receive subsidies from the program. For one of 14 providers tested, ITCN did not obtain evidence that the provider was licensed in the State of Nevada to provide day care services. Recommendation: Th...

Condition and Context: The program guidelines require ITCN to verify the safety of all providers who receive subsidies from the program. For one of 14 providers tested, ITCN did not obtain evidence that the provider was licensed in the State of Nevada to provide day care services. Recommendation: The auditors recommended that ITCN adhere to its policy of only providing subsidies to State of Nevada licensed child care centers. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN implemented a Licensing Verification Checklist in every provider file. Also, a quarterly licensing review against the state registry, including a pre-payment license verification before any subsidy is issued. The Compliance Officer will conduct a semi-annual file spot-check on provider files. Anticipated Completion Date: Ongoing; the first quarterly licensing review under the new process was completed in September 2025, with the next review in December 2025.

View Audit 393293

Finding 1181968 (2022-104)

Material Weakness 2022

Inter-Tribal Council of Nevada, Inc.

NV

Internal Control / Segregation of Duties

Condition and context: For FAL 10.557, the program guidelines require each agency to provide nutrition education to each participant and document nutritional risk of each participant. For FAL 93.575, the program guidelines require ITCN to create a sliding scale of copayments and establish a payment ...

Condition and context: For FAL 10.557, the program guidelines require each agency to provide nutrition education to each participant and document nutritional risk of each participant. For FAL 93.575, the program guidelines require ITCN to create a sliding scale of copayments and establish a payment rate schedule for parents. Recommendation: The auditors recommended that ITCN adhere to its policy of providing nutritional education to each participant. The auditors also recommended that ITCN charges participants the correct amount according to the sliding scale of fees. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: Staffing stabilized in WIC/CCDF. Since Aug 2023, the WIC Director implemented daily chart audits, staff training and guides, and policy updates to ensure nutrition education and risk documentation. System improvements are being evaluated to better tag services by appointment type. CCDF sliding fee scale and payment rate schedule were updated and re-issued. The staff will verify correct application at eligibility determination. Anticipated Completion Date: Ongoing, the next internal compliance review will be in March 2026.

View Audit 393293

Finding 1181960 (2022-101)

Material Weakness 2022

Inter-Tribal Council of Nevada, Inc.

NV

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.303

Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommenda...

Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommendation: The auditors recommended that ITCN implement the recommendations noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: This broad finding is being addressed by the corrective actions above. Fiscal contractors are providing quarterly compliance monitoring. ITCN’s Compliance Officer has initiated quarterly internal monitoring reviews. Migration to MIP/Microix will enhance reporting and compliance tracking. Training will ensure fiscal staff maintain compliance standards long-term. Anticipated Completion Date: The additional monitoring began in June 2024, with integration and staff training to be fully complete by June 2026.

View Audit 393293

Finding 1179321 (2022-011)

Material Weakness 2022

The Young Men's Christian Association of Metropolitan Denver

CO

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.309 § 200.77

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreem...

Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete

View Audit 391683

Finding 1175934 (2022-004)

Material Weakness 2022

Head Start of Lane County

OR

Significant Deficiency Internal Control / Segregation of Duties

Head Start of Lane County has created a timeline in partnership with Wipfli to ensure the completion of delinqunet audits and to ensure timely completion after August 31, 2026

View Audit 389901

Finding 1175570 (2022-008)

Material Weakness 2022

Dewey County

OK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.

View Audit 389361

Finding 1175569 (2022-007)

Material Weakness 2022

Dewey County

OK

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

The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.

View Audit 389361

Finding 1174933 (2022-018)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174931 (2022-016)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency § 200.303

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174930 (2022-015)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

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

Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained ...

Finding 2022-015 Allowable Costs and Activities Individual(s) Responsible: Tribal Council; Michelle Thomas, Acting Executive Director; Tyce Martin, HR Generalist; Program Directors; and Enterprise Managers. Action: The current Tribal Council will ensure that all required documentation is maintained as supporting backup for all purchase requisitions, including proper signatures, prior authorization, and related approvals. In addition, all employees will have appropriate Personnel Action Notices (PANs) on file, and all timesheets will be properly completed and signed by both the employee and their supervisor. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1173240 (2022-005)

Material Weakness 2022

New Space Nexus

NM

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties

Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monit...

Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monitored running budget, and the Executive Director will review and approve each report prior to submission to AFRL. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by March 31, 2023.

View Audit 386730

Finding 1173236 (2022-001)

Material Weakness 2022

New Space Nexus

NM

Eligibility Reporting Significant Deficiency

Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9...

Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.

View Audit 386730

Finding 1172706 (2022-008)

Material Weakness 2022

Northwest Indian College

WA

Eligibility Reporting Significant Deficiency § 200.303 § 200.328 § 200.329

Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...

Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Corrective Action Plans

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