Corrective Action Plans

Finding 1216171 (2022-008)

Material Weakness 2022

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filin...

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filings and maintains a working spreadsheet of items sent. In addition, Accounting has implemented a tickler system to remind staff to submit financial reports to Engineering or the grantor.

View Audit 402648

Finding 1216167 (2022-006)

Material Weakness 2022

Virgin Islands Port Authority

VI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.

View Audit 402648

Finding 1214370 (2022-006)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Internal Control / Segregation of Duties

2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...

2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 401032

Finding 1214365 (2022-001)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...

2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.

View Audit 401032

Finding 1214251 (2022-002)

Material Weakness 2022

Urban Partnerships Community Development Corporation

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management ...

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management will implement proper policies and procedures to ensure the Organization and Affiliates' activities are properly recognized. In addition, management will reconcile the activities of the Organization and Affiliates quarterly against the financial system and ensure activities are recognized properly at year-end.

View Audit 400976

Finding 1213892 (2022-005)

Material Weakness 2022

Town of Livermore Falls

ME

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

CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: The processing of invoices for the warrant has been corrected as of December 2023. The Procurement Policy was approved and implemented by the Select Board on January 23, 204.

View Audit 400731

Finding 1213890 (2022-006)

Material Weakness 2022

Town of Livermore Falls

ME

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

CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy that will address this deficiency. The Select Board will review this draft at their meeting in February or March 2024, edits will be made and then it will be sent to legal for final review before adoption. This policy will include sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: It is anticipated that the Internal Controls Policies and Procedures will be approved and adopted by June 2024 by the Select Board. Implementation will be July 1, 2025 with the new chart of accounts.

View Audit 400731

Finding 1211144 (2022-005)

Material Weakness 2022

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400353

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 Questioned Costs Cash Management

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

Questioned Costs 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

Questioned Costs Subrecipient Monitoring Reporting § 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

Questioned Costs 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 Questioned Costs § 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

Questioned Costs 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

Corrective Action Plans

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