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Corrective Action Plans

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Finding 1156844 (2024-013)
Material Weakness 2024
State of Missouri
MO
Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2424-013 - Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2424-013 - Child Care Payments Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 12/31/2025 Corrective action planned is as follows: DESE agrees with the auditor's finding. DESE is working on strengthening internal controls within the Child Care Data System (CCDS) to prevent duplicate payments and overpayments due to absences and attendance and ensure sliding fees for each child are correct. DESE has worked with the Administration for Children and Families on the specific requirements related to correcting overpayments. DESE has paid the providers with underpayments.
View Audit 369219 Questioned Costs: $1
Finding 1156836 (2024-016)
Material Weakness 2024
State of Missouri
MO
Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting § 200.303
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Missouri Department of Economic Development (DED) Audit Finding Number: 2024-016 - DED FFATA Reporting Name of the contact person responsible for corrective action: Nikki Wrinkles Anticipated completion date...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Missouri Department of Economic Development (DED) Audit Finding Number: 2024-016 - DED FFATA Reporting Name of the contact person responsible for corrective action: Nikki Wrinkles Anticipated completion date for corrective action: FFATA Reporting was completed November 8, 2024. Internal control was adopted April 28, 2025. Corrective action planned is as follows: FFATA Reporting: (a) In the foreseeable future, if the Missouri Office of Administration (OA) is the recipient of a federal grant and DED agrees to administer the federal grant, DED will attempt to ensure that the issue of which agency is responsible for filing the Federal Funding Accountability and Transparency Act (FFATA) report is clearly delineated. In the event this is not delineated by the time a FFATA is due to be filed in the FFATA Subaward Reporting System (FSRS), DED will simply proceed to file using the Unique Entity Identifier (UEI) on the grant agreement between OA and the federal agency. (b) DED did file the FFATA report on November 8, 2024. (c) DED did not anticipate any additional awards being made from the Coronavirus Capital Projects Fund (CPF), and no such awards have been made since March 2022. If additional awards are made from the CPF, DED will follow the internal control process it has now established. Internal controls: DED has established an internal control process for the CPF in the event additional awards are made in the future and will use OA’s UEI for any such future reporting. A copy of the internal control policy regarding FFATA reporting compliance is included with this CAP.
View Audit 369219
Finding 1156833 (2024-017)
Material Weakness 2024
State of Missouri
MO
Subrecipient Monitoring Matching / Level of Effort / Earmarking HUD Housing Programs § 200.303
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Higher Education and Workforce Development Audit Finding Number: 2024-017 – DHEWD FFATA Reporting Name of the contact person responsible for corrective action: Elizabeth (Liz) Roberts Anticipat...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: Department of Higher Education and Workforce Development Audit Finding Number: 2024-017 – DHEWD FFATA Reporting Name of the contact person responsible for corrective action: Elizabeth (Liz) Roberts Anticipated completion date for corrective action: January 1, 2025 Corrective action planned is as follows: In response to the auditor’s report finding, we dedicated a team of staff to review our subaward files for the date range in question. Staff compared our subawards from that time to federal reporting system data and reported any subawards that were missing. We will continue to monitor these historical files for their reported status as we encounter them through the course of our current normal business activities. We have strengthened internal controls related to FFATA reporting for the WIOA cluster, and our new federal award reporting and monitoring process is outlined below: On the fifteenth day of every month following the subaward execution month, staff utilize a spreadsheet populated with subaward data the previous month to enter subaward information for that month into the federal reporting system. After the subawards have been reported in the system, the full subaward report data and their submission receipts (proof of submission) are saved to internal electronic files. Each file now features a descriptive file name to which allows for an easily searchable, historical record. • Files are organized by FY and report month • Each month now includes a spreadsheet of the awards reported • Each report is now categorized by grant, and reports with multiple subawards per grant now contain a cover page with table of contents summarizing the subaward report data included on the subsequent pages with any changes indicated in red • Each file now contains Auditor notes where necessary, indicated in red After the reports are submitted, staff now sends the reports and spreadsheet summary for each month to a supervisor to review, who compares them with each executed subaward notification email sent to the executed subaward notification group in the previous month. The supervisor responds with monitoring results (e.g. missing, incorrect, complete). Reports are adjusted as necessary based on this review. The supervisor’s emailed approval response is saved to the file. DHEWD will provide proper FFATA reporting training to staff. The process outlined above will evolve slightly since, as of March 8, 2025, FSRS.gov has transitioned to SAM.gov. SAM.gov features enhancements that support improved reporting accuracy, such as auto-checking for previously reported subawards to avoid duplication.
View Audit 369219
Finding 1156827 (2024-014)
Material Weakness 2024
State of Missouri
MO
School Nutrition Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: MO Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2024-014 - DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods Anticipated comple...
State of Missouri Single Audit Corrective Action Plan Year Ended June 30, 2024 State Agency: MO Department of Elementary and Secondary Education (DESE) Audit Finding Number: 2024-014 - DESE FFATA Reporting Name of the contact person responsible for corrective action: Shelley Woods Anticipated completion date for corrective action: 7/1/2025 Corrective action planned is as follows: The agency agrees with the auditor's finding. DESE has changed internal procedures to ensure FFATA reporting follows applicable requirements. DESE is designating a Federal Compliance Coordinator to submit all FFATA reporting as opposed to each section Fiscal Liaison uploading the report. The terms and conditions for each grant award will be reviewed by the Federal Compliance Coordinator to determine if FFATA is applicable, and then the Federal Compliance Coordinator will work the Fiscal Liaison to collect and report the information required under FFATA.
View Audit 369219
Finding 1156819 (2024-002)
Material Weakness 2024
Basic Nwfl, Inc.
FL
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303
To address the eligibility documentation issue identified during the audit, BASIC NWFL, Inc. will improve how eligibility files are reviewed by using a checklist and having two staff members verify each file. Staff will get regular training on federal rules, and internal checks will be done frequent...
To address the eligibility documentation issue identified during the audit, BASIC NWFL, Inc. will improve how eligibility files are reviewed by using a checklist and having two staff members verify each file. Staff will get regular training on federal rules, and internal checks will be done frequently to catch any problems early. Policies will be updated to make sure marital status and household size are clearly documented, and a eligibility specialist will oversee the process and report monthly to management. These steps will help ensure all eligibility decisions are properly supported.
View Audit 369207
Finding 1156801 (2024-001)
Material Weakness 2024
Louisville Housing Opportunities and Micro-Enterprise Community Develo
KY
Reporting Matching / Level of Effort / Earmarking
September 26, 2025 Response to Findings – Views of Responsible Officials and Corrective Active Plan LHOME respectfully submits the following response to the federal award finding for the year ending December 31, 2024. Hicks and Associates, CPAs, PLLC 1795 Alysheba Way, Suite 6206 Lexington, KY 40509...
September 26, 2025 Response to Findings – Views of Responsible Officials and Corrective Active Plan LHOME respectfully submits the following response to the federal award finding for the year ending December 31, 2024. Hicks and Associates, CPAs, PLLC 1795 Alysheba Way, Suite 6206 Lexington, KY 40509 Audit Period: January 1, 2024 – December 31, 2024 The findings from the FYE December 31, 2024, schedule of findings and questioned costs are discussed below and include LHOME’s management responses. Finding: 2024-001 Reporting – Performance Goals and Measures RECOMMENDATION: We recommend that LHOME attempt to expand its target reach by increasing marketing and by optimizing its products and services to appeal to new customers/borrowers. LHOME could also collaborate with CDFI and their recommendations on meeting federal program benchmarks when external factors are present and influential. RESPONSE: LHOME entered into a grant agreement in February 2023 to launch a new “strong roots” program. The grant performance goals and metrics (PG&M) were determined based on the grant application. The strong roots program supported loans to existing businesses with at least two years of operating history and focused on expansion. The minimum loan amount for the strong roots program was $50,000. The first period of performance (POP) ending December 31, 2024 and the goal was to disburse $437,500 through the strong roots program. The rules to prorate PG&Ms to match the cash award were not yet in place within the CDFI. LHOME successfully disbursed $125,000 in loans but below the goal of $437,500, creating the instance of non-compliance. No sanctions were imposed by the CDFI since this is the first POP for the grant. Response to Findings – Views of Responsible Officials and Corrective Active Plan - continued This shortfall is primarily due to the following factors: • CDFI rules require full achievement of goals stated in the application regardless of the awarded amount. Goals are not prorated to align with the actual cash award. • Restricted cash flow among prospective borrowers, limiting their ability to qualify for larger loans. • Declining consumer confidence and increased inflation, resulting in lower demand and a shift toward smaller loan requests. • Economic instability and increased delinquency rates on existing loans, creating additional pressure on organizational cash flows. • Launching a new loan product in a challenging economic environment, which required more time for market acceptance and borrower readiness. Corrective Actions: 1. Request a grant amendment to decrease Performance Goals and Metrics to align with the actual cash award. 2. Strengthen Market Outreach and Referral Networks • Expand marketing activities to increase awareness of the grant-funded loan product. • Partner with local banks, credit unions, business development organizations, and technical assistance providers to increase referrals and reach businesses that meet the loan size criteria. • Use targeted campaigns focusing on businesses with demonstrated growth potential. 3. Enhance Borrower Readiness and Capacity • Work closely with external development service providers to ensure their understanding of LHOME’s underwriting requirements. • Require external development to address cash flow issues, strengthen financial statements, and prepare borrowers to qualify for larger loans. 4. Develop a Business Incubator Program • Explore the development of a business incubator designed for existing businesses with growth potential, offering technical assistance, mentorship, and access to financing pathways. • Provide some structured support to help businesses scale operations to qualify for $50,000+ loans. Through the combined efforts of grant amendments, expanded marketing, targeted development, and stronger partnerships, LHOME is expected to meet performance goals and metrics for the CDFI compliance by the end of fiscal year 2025. Respectfully, Keith Talley, Sr President & CEO
View Audit 369186
Finding 1156777 (2024-003)
Material Weakness 2024
Special Children's Charities
IL
Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302
The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved acco...
The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved accountability, accurate reporting, and compliance with federal requirements.
View Audit 369106
Finding 1156733 (2024-001)
Material Weakness 2024
Oakland Livingston Human Service Agency
MI
Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.308 § 200.403
The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior ...
The Agency agrees with the finding. We will provide training to program managers who are approving program expenditures to ensure proper allocation of costs to the appropriate grant cycles. We will also update our purchasing procedures to ensure that the proper allocation of costs is reviewed prior to supervisor's approval of the cost.
View Audit 369077
Finding 1156714 (2024-003)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were ...
Finding 2024-003 Coronavirus State and Local Fiscal Recovery Funds/ National Bioterrorism Hospital Preparedness Program/ Block Grants for Community Mental Health Services (21.027/93.889/93.958) Management did not have sufficiently designed internal controls to ensure that effort certifications were completed for all individuals working on multiple federal programs. Management Response: To address the identified deficiency, management is introducing standardized procedures to ensure that effort certifications are completed accurately and on time for all program staff. Program staff will receive targeted training, and a monitoring process will be implemented to support ongoing reviews. In addition, improvements to the effort tracking methodology are being considered to enhance the accuracy of employee time reporting across multiple federal grants, thereby strengthening compliance and minimizing the risk of reporting errors. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Venice Northe, Grants Accounting Manager and Program teams. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156705 (2024-004)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Matching / Level of Effort / Earmarking
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibil...
Finding 2024-004 Opiod STR (ALN 93.788) Management did not have sufficiently designed and documented - internal controls to ensure that all participants in the program were eligible to receive services through the program. Management Response: A more complete procedure to verify participant eligibility will be developed. This procedure will include detailed steps and required documentation, supported by a standardized eligibility checklist to guide staff in confirming and accurately recording participant eligibility. Additionally, all program staff involved in intake and eligibility determination will be trained on the new procedure. Contact Person - Responsible for Corrective Action: Elizabeth LaRoy, Program Manager Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156697 (2024-002)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded...
Finding 2024-002 Crime Victim Assistance (ALN 16.575) The Organization has internal controls in place to ensure employees’ effort certifications are approved. However, the Organization did not have internal controls to ensure that allchanges in employees’ certified effort were communicated, recorded and charged to the grant. Management Response: Management will develop and implement written procedures to ensure the timely communication of discrepancies identified during the effort certification process to the Grant Accounting team for appropriate review and adjustment. Program staff will be trained in the new process, and reviews will be conducted to monitor compliance and ensure the continued effectiveness of the process. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director and Venice Northe, Grants Accounting Manager. Anticipated Completion Date: December 31, 2025.
View Audit 369065
Finding 1156691 (2024-001)
Material Weakness 2024
Advocate Aurora Health, Inc.
IL
Eligibility Reporting Matching / Level of Effort / Earmarking
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting document...
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained. As a result, no corrective action will be taken. Contact Person - Responsible for Corrective Action: Jen Agnello, Program Manager Anticipated Completion Date: N/A
View Audit 369065
Finding 1156666 (2024-005)
Material Weakness 2024
Adams County
OH
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Special Tests & Provisions
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
View Audit 369025
Finding 1156661 (2024-004)
Material Weakness 2024
Marquette County
WI
Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children an...
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services State Program ID Number and Title: 395.168 Specialized Transit County Operating Aids (Elderly & Disabled) State Agency: Wisconsin Department of Transportation State Program ID Number and Title: 435.000283 IMAA State Share State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including appropriate review and approval of expenditures. Condition/Context: During our testing, we were unable to view approval for the following number of payroll expenditures in each program: • 93.778: 13 out of 20 expenditures tested. • 435.000561/000681, 437.3561/3681: 7 out of 40 expenditures tested. • 435.560100: 14 out of 20 expenditures tested. For programs 395.168 and 435.000283, these are carried over from the prior year as controls have not changed within the system. These samples were not statistically valid. Corrective Action Plan Corrective Action Planned: In response to Finding 2024-004 regarding Internal Control Over Financial Reporting, note that the County is aware that there is lack of controls over its year-end financial reporting process. The County will endeavor to evaluate the need to increase additional staff to meet the deficiencies noted in the finding. However, due to its size, the County does not feel it is cost-effective to hire the number of employees needed to complete these task in house at this point in time and will rely on an outside audit firm. Administration is aware the current payroll and financial system allows to only go back to view payroll approvals within one year. Name(s) of Contact Person(s) Responsible for Corrective Action: Ron Barger, Marquette County Administrator Anticipated Completion Date: Administration will examine the lack of internal financial reporting on a yearly ongoing basis.
View Audit 369021
Finding 1156650 (2024-002)
Material Weakness 2024
Mahnomen County
MN
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions
Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will implement procedures to ensure that federal wage rate standards are followed for federal grant purchases. Completion Date – 9/30/2025
Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will implement procedures to ensure that federal wage rate standards are followed for federal grant purchases. Completion Date – 9/30/2025
View Audit 369009
Finding 1156624 (2024-002)
Material Weakness 2024
Housing Authority of Kansas City, Missouri
MO
HUD Housing Programs Material Weakness Reporting
Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action t...
Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAKC will monitor the monthly SEMAP Indicator report and monitor the PIC dashboard to ensure all 50058 errors are corrected and uploaded in a timely manner. HAKC will also pull the ADHOC from PIC to verify the records. HAKC will continue working with the HUD PIC coach monthly to correct all errors. HAKC will complete the initial process and complete ongoing compliance reviews. Name(s) of the contact person(s) responsible for corrective action: Lisa Earnest, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 4/30/2026
View Audit 368975
Finding 1156618 (2024-004)
Material Weakness 2024
Hendricks County
IN
Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of ...
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: The Grant Administrator will monitor all claims that will be used for the quarter and send them to the reporting agent to report after the quarter ends. She will be diligent to track any claims coming in outside of that quarter so that reporting is accurate. She will provide the reporting agent with all claims relevant to that quarter’s report. Anticipated Completion Date: This will be done quarterly starting with the quarter ending on September 30th, 2025. The Grant Administrator will submit these claims to the reporting agent one week after the quarter ends. The Financial Administrator will sign o􀆯 on the LOW report to verify the claims match.
View Audit 368974
Finding 1156603 (2024-001)
Material Weakness 2024
Bebashi - Transition to Hope
PA
Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329
On behalf of Bebashi – Transition to Hope, I am submitting this corrective action plan in response to the material weakness finding identified in our recent federal audit. The finding noted a lack of effective internal controls over the maintenance of accurate accounting records, including the trial...
On behalf of Bebashi – Transition to Hope, I am submitting this corrective action plan in response to the material weakness finding identified in our recent federal audit. The finding noted a lack of effective internal controls over the maintenance of accurate accounting records, including the trial balance, general ledger, and the Schedule of Expenditures of Federal Awards (SEFA) and state financial assistance. These deficiencies resulted in material audit adjustments to the current year’s financial statements, multiple versions of the trial balance due to reconciling issues, and audit delays related to unreconciled supporting documentation. We take these findings with the utmost seriousness. As stewards of federal funds, it is our fiduciary duty to maintain strict compliance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR Part 200), as well as applicable state financial requirements. Corrective Action Plan 1. Strengthening Internal Controls o We are implementing enhanced internal control procedures to ensure timely reconciliation of the trial balance and general ledger. o Monthly reconciliations will now be prepared by the Finance Department, reviewed by the Chief Operating Officer, and formally approved by the President & Chief Executive Officer prior to closing. o Quarterly oversight reporting will also be provided to the Bebashi Board of Directors. 2. Accounting System Improvements o We will establish a standardized process to ensure one official version of the trial balance is maintained, with all adjustments tracked and documented in accordance with Generally Accepted Accounting Principles (GAAP). o We are upgrading our financial reporting system to include automated reconciliation checks, audit trails, and controls that will minimize the risk of discrepancies. 3. Staff Training and Accountability o Finance staff will undergo mandatory annual training on federal compliance, SEFA preparation, and reconciliation best practices. o Roles and responsibilities will be clearly defined, with a segregation of duties to prevent misstatements and errors. 4. Audit Readiness and Documentation o A comprehensive audit binder will be prepared and maintained to ensure that supporting documentation reconciles with the trial balance prior to submission. o A compliance calendar will be developed to track critical deadlines, reconciliation reviews, and reporting requirements. 5. Board and Executive Oversight o The Bebashi Board of Directors, through its Finance and Audit Committees, along with the President & CEO, will provide governance oversight of this corrective action plan. o Quarterly progress reports will be submitted to the Board, and the CEO and Board will formally document oversight in meeting minutes to ensure accountability and compliance. Responsible Party: The Finance Director, in collaboration with the Chief Operating Officer and with final accountability to the President & CEO as well as the Bebashi Board of Directors, will be responsible for implementing and monitoring this corrective action plan. Anticipated Completion Date: All corrective measures will be completed within ninety (90) days of the date of this letter, with ongoing monitoring and governance oversight by the CEO and Board of Directors to ensure sustainability. We regret the deficiencies that led to this finding and are committed to taking the corrective actions necessary to strengthen our financial management systems. Bebashi – Transition to Hope is dedicated to full compliance with federal and state requirements and to safeguarding the integrity of public funds entrusted to us. Respectfully submitted, Sincerely, Sebrina Tate President & Chief Executive Officer Bebashi – Transition to Hope On behalf of the Bebashi Board of Directors
View Audit 368952
Finding 1156569 (2024-003)
Material Weakness 2024
Housing Authority of the City of Omaha
NJ
HUD Housing Programs Significant Deficiency Matching / Level of Effort / Earmarking
U.S. Department of Housing and Urban Development 2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – PIC Submissions Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explan...
U.S. Department of Housing and Urban Development 2024-003 Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 – PIC Submissions Recommendation: We recommend the Authority to designate an individual to ensure accurate HUD-50058 information is inputted into the PIC system timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will increase oversight in the Section 8 Housing Choice Voucher program to ensure that established internal control policies are being followed. HUD-50058s are transmitted monthly. Some transmissions have PIC errors while other files that are submitted late due to annual recertification completion. The Authority has plans in place to ensure quality control and resubmission of any errors and to improve timely annual completion and submission. Name(s) of the contact person(s) responsible for corrective action: Philisa Smith, HCV Director Planned completion date for corrective action plan: December 31, 2026
View Audit 368905
Finding 1156551 (2024-004)
Material Weakness 2024
Andrew County Health Department
MO
Cash Management Reporting Significant Deficiency
Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and perf...
Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and performance reports.
View Audit 368888
Finding 1156543 (2024-002)
Material Weakness 2024
Samaritas and Subsidiaries
MI
Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Finding 1156525 (2024-001)
Material Weakness 2024
Sustainable Fisheries Partnership Foundation
HI
Cash Management Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025
View Audit 368873
Finding 1156486 (2024-001)
Material Weakness 2024
The George E. Brown United States-Mexico Foundation for Science
DC
Matching / Level of Effort / Earmarking
The Foundation pursued legal action because the way in which the IMPI withdrew from our agreement was found to be illegal. The Mexican court agreed with our position, and by the end of 2021, the Foundation had received a favorable resolution on the 2020 lawsuit. This led to initial meetings with IMP...
The Foundation pursued legal action because the way in which the IMPI withdrew from our agreement was found to be illegal. The Mexican court agreed with our position, and by the end of 2021, the Foundation had received a favorable resolution on the 2020 lawsuit. This led to initial meetings with IMPI's renewed top management, but unfortunately, we were unable to reset the funds. In June 2022, the Foundation formally requested that the IMPI reset the funds in order to continue functioning under the agreement, as a legally developed addendum had been created to supplement the original agreement. There were hectic changes in top management at the Mexican Ministry of Economy and the IMPI in 2022, resulting in unproductive efforts from previous negotiations. Then, in July 2023, the Foundation submitted a second lawsuit to enforce the one won in 2021, which was accepted by the court. On 13 September 2024, the Foundation was notified by the court of a favorable resolution regarding this second lawsuit. The IMPI still has one final opportunity to contest this resolution, although the probability of changing the outcome is minimal. Consequently, the Foundation's executives and its Board of Governors resumed communication with the IMPI's legal team to accelerate the resetting of the funds and the collaboration agreement. This was unsuccessful. Although the final ruling generally favored the Foundation, FUMEC filed a direct appeal for constitutional protection, claiming that the returns generated should not be limited to December 2022 but should instead be accumulated and calculated until IMPI actually made the payment; that is, until the month of 2024 in which IMPI complied with the ruling handed down on July 1, 2024. The court revoked the contested trial of July 1, 2024, and issued a new ruling, reiterating the considerations regarding the period and the amounts that IMPI is obliged to pay to FUMEC, in order to fully restore FUMEC's infringed subjective right. In compliance with this ruling, on September 8, 2025, the court issued a new ruling considering that the Collaboration Agreement was still in force and that IMPI had not demonstrated that it had fulfilled its obligations. Consequently, and reiterating its previous ruling, the court granted IMPI a period of no more than four months to comply with the Collaboration Agreement. IMPI was therefore required to reimburse the principal funds of $5 million USD to FUMEC’s endowment and pay the returns due for the period from August 2020 to May 2024. Proposed completion date – 2Q2026. Contact person – Eugenio Marin, Executive Director
View Audit 368844
Finding 1156477 (2024-002)
Material Weakness 2024
Lifewire
WA
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303 § 200.430
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
View Audit 368819
Finding 1156471 (2024-001)
Material Weakness 2024
Emergency Food Network of Tacoma and Pierce County
WA
Questioned Costs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.430
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee sp...
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.
View Audit 368815 Questioned Costs: $1
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