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Corrective Action Plans

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Finding 1218193 (2024-001)
Material Weakness 2024
City of Eastlake
OH
Matching / Level of Effort / Earmarking § 200.302 § 200.328 § 200.329
All federal programs requiring engineering assistance will be also be tracked internally for compliance.
All federal programs requiring engineering assistance will be also be tracked internally for compliance.
View Audit 404427
Finding 1218154 (2024-002)
Material Weakness 2024
Urban Indian Center of Salt Lake
UT
Matching / Level of Effort / Earmarking Questioned Costs Procurement, Suspension & Debarment § 200.430
FINDING 2024-002 Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect ...
FINDING 2024-002 Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non-Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job-costing system implemented. Auditee Response: Organization believes that prior leadership and lack of supervision allowed paychecks to be approved without the proper flow. FY24 Turnover was roughly 75% in leadership and 60% across the organization. Corrective Action Plan: UICSL moved away to Paycom early 2024 to better help account for Labor Allocation and Grant Codes. With Paycom, employees are automated to each program and there is a designated reporting function allowing us to review what is assigned. UICSL going into 2025 has better defined leadership and Directors for each division so there are clearly defined approvers and supervisors for each purchase and transaction – leadership turnover was high. Person Responsible: Som Chivukula, Finance Director; Matt Poss, Executive Director; Eva Leyer, Human Resources Manager Timeline: UICSL filled all leadership positions by mid-2025 and went through two organizational restructures, creating more mid-level management. This will help ensure compliance with FY25 Audit.
View Audit 404346
Finding 1218063 (2024-004)
Material Weakness 2024
Community Health Service, Inc.
MN
Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness
Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Ensure complete documentation is obtained and retained. - Implement monitoring and periodic reviews. - Provide staff training. Responsible Parties: Chief Executive Officer and Chief Financial Officer
Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Ensure complete documentation is obtained and retained. - Implement monitoring and periodic reviews. - Provide staff training. Responsible Parties: Chief Executive Officer and Chief Financial Officer
View Audit 404217
Finding 1218062 (2024-003)
Material Weakness 2024
Community Health Service, Inc.
MN
Cash Management Internal Control / Segregation of Duties Questioned Costs § 200.305
Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and Chief Financial ...
Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and Chief Financial Officer
View Audit 404217
Finding 1218038 (2024-005)
Material Weakness 2024
Papa Ola Lokahi
HI
Material Weakness Matching / Level of Effort / Earmarking
Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Fina...
Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2024-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. Contractor Performance Collection and Substantiation – November 2024 The Organization has incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. The current practices of the Organization, from the above date, to the present period of the report dated June 17, 2026, is consistent with such developed procedures.
View Audit 404207
Finding 1218030 (2024-004)
Material Weakness 2024
Papa Ola Lokahi
HI
Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512 § 200.514
Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a del...
Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) continue to challenge the Organization, however, the Organization notes the status and progress of the following single audits: • June 30, 2022, filed in the Federal Audit Clearinghouse (FAC) in February 2025. • June 30, 2023, filed in the FAC in March 2026. • June 30, 2024, final review by Board in progress, projected filing in the FAC in June 2026. • June 30, 2025, engagement field work in progress with projected filing date no later than September 2026. • June 30, 2026, engagement letter signed with scheduled field work to commence after the June 30, 2025, audit FAC filing; projected to be completed with related FAC filing, no later than March 2027. The Organization notes the corrective actions that have been implemented, regarding internal controls to ensure compliance with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form: A. Internal Controls in Practice Since Inception of New Auditor Engagement – April 2023. As noted in the prior year corrective action response, the Organization established internal compliance controls related to the timely submission of single audit reports. Such process and review controls are implemented by the director of administrative operations, chief of staff (since December 2024), and chief executive officer; and subsequently communicated to the Board finance sub-committee and full Board, including the documented Board action(s) taken (e.g., Board agenda, minutes). B. Financial Policies and Procedures – May 2025. By May 2025, the Organization completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. Note the internal control policy of the Organization documents process and review controls, which were already in practice, applying to the timely filing of single audit reports. The current practices of the Organization, to the present period of the report dated June 17, 2026 is consistent with established process and review controls for timely submission of single audit reports.
View Audit 404207
Finding 1217939 (2024-003)
Material Weakness 2024
St. Luke's Hospital
ND
Special Tests & Provisions Questioned Costs Material Weakness § 200.303
Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although ...
Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although management obtained a waiver for the noncompliance, the lack of adequate policies governing proper funding of reserve increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Corrective Action Plan: Management will review and enhance internal control policies to ensure that there is proper funding of the reserve accounts. Responsible Individuals: Jody Nelson, CEO and Megan Peterson, CFO
View Audit 404103
Finding 1217419 (2024-010)
Material Weakness 2024
Community Legal Aid Society, Inc.
DE
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.1 § 200.303 § 200.32
This has been corrected with current staff. We are making sure that all reports are filed on time and correctly. Responsible Official: Director of Finance Expected Completion Date: The report was corrected 4/14/2026 with the completion of the 2025 SLFRF Compliance Report.
This has been corrected with current staff. We are making sure that all reports are filed on time and correctly. Responsible Official: Director of Finance Expected Completion Date: The report was corrected 4/14/2026 with the completion of the 2025 SLFRF Compliance Report.
View Audit 403627
Finding 1217363 (2024-001)
Material Weakness 2024
PELHAM-BATESVILLE FIRE DEPARTMENT
SC
Reporting Matching / Level of Effort / Earmarking
The Town is working with its external auditor to issue the Single Audit for the year ended December 31, 2024. Anticipated Completion Date: May 28, 2026
The Town is working with its external auditor to issue the Single Audit for the year ended December 31, 2024. Anticipated Completion Date: May 28, 2026
View Audit 403550
Finding 1217307 (2024-005)
Material Weakness 2024
Anna Marie's Alliance
MN
Cash Management Significant Deficiency Matching / Level of Effort / Earmarking § 200.303
Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagree...
Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdowns and reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has designated an individual to review and approve the cash reimbursement requests and reports prior to submission. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025
View Audit 403475
Finding 1217305 (2024-003)
Material Weakness 2024
Anna Marie's Alliance
MN
Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.326
Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement wi...
Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will apply its current procurement policy to new and existing vendors in order to comply with applicable procurement requirements. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025
View Audit 403475
Finding 1217290 (2024-001)
Material Weakness 2024
North Central Alabama Regional Council of Local Governments
AL
Subrecipient Monitoring Reporting Significant Deficiency
FINDINGS - U.S ECONOMIC DEVELOPMENT ADMINISTRATION, ALN# 11.307 SIGNFICANT DEFICIENCY Finding 2024-001 - Reporting: The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Aydjt finding 2024-001: Ba...
FINDINGS - U.S ECONOMIC DEVELOPMENT ADMINISTRATION, ALN# 11.307 SIGNFICANT DEFICIENCY Finding 2024-001 - Reporting: The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Aydjt finding 2024-001: Background: The FY2024 Semi-Annual Revolving Loan Fund Financial Reports were not submitted within the required timeframe. Current accounting and RLF management were not responsible for report preparation during the reporting period and unable to verify the specific circumstances that resulted in the late submissions. The finding indicates that report controls and monitoring procedures in place at the time were not sufficient to ensure required deadlines were met primarily due to accounting and RLF staff turnover. Conclusion: Staffing turnover was mitigated in Fall 2025 allowing significant progress towards existing corrective action plan. Progress was as follows: • Developing updated and written procedures for RLF reporting. • Ensuring current key staff members and management have access to reporting instructions and supporting documentation. • Ensuring periodic management review of reporting deadlines and requirements.
View Audit 403451
Finding 1217228 (2024-005)
Material Weakness 2024
Family Promise of Hendricks County Inc.
IN
Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs § 200.303
Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and...
Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and approving match calculations and supporting documentation as well as requiring independent review and documented approval of match calculations by a staff member not involved in the preparation.
View Audit 403362
Finding 1216953 (2024-011)
Material Weakness 2024
City of Waverly
OH
Reporting Matching / Level of Effort / Earmarking Program Income § 200.329
The Village will submit required reports on time.
The Village will submit required reports on time.
View Audit 403245
Finding 1216735 (2024-001)
Material Weakness 2024
STEPS to Recovery Homes
AZ
Reporting Matching / Level of Effort / Earmarking Special Tests & Provisions
Management of the Organization has an accounting firm engaged who will perform future required audits.
Management of the Organization has an accounting firm engaged who will perform future required audits.
View Audit 403178
Finding 1216684 (2024-006)
Material Weakness 2024
American Thoracic Society, Inc.
NY
Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.320
Views of Responsible Officials and Planned Corrective Actions: ATS has drafted an organization-wide procurement policy to ensure it includes all the Uniform guidance procurement elements. The draft will be reviewed by senior management for comment prior to formal issuance.
Views of Responsible Officials and Planned Corrective Actions: ATS has drafted an organization-wide procurement policy to ensure it includes all the Uniform guidance procurement elements. The draft will be reviewed by senior management for comment prior to formal issuance.
View Audit 403116
Finding 1216628 (2024-001)
Material Weakness 2024
My Sister's Place, Inc.
DC
Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking
Response: MSP now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY 2024 audit. Additionally, policies and procedures have been updated to reflect appropriate suspension and debarment considerations.
Response: MSP now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY 2024 audit. Additionally, policies and procedures have been updated to reflect appropriate suspension and debarment considerations.
View Audit 403101
Finding 1216626 (2024-002)
Material Weakness 2024
My Sister's Place, Inc.
DC
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430
Response: MSP plans to implement changes overall to timekeeping processes to ensure that payroll costs accurately reflect the work performed and to reconcile and true up any budget estimates on a consistent basis.
Response: MSP plans to implement changes overall to timekeeping processes to ensure that payroll costs accurately reflect the work performed and to reconcile and true up any budget estimates on a consistent basis.
View Audit 403101
Finding 1216555 (2024-007)
Material Weakness 2024
Glacierland Resource Conservation and Development Council, Inc.
WI
Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking
Finding 2023-007 ● Criteria or Specific Requirement: Title 2 U.S. Code of Federal Regulations section 200.303 requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal...
Finding 2023-007 ● Criteria or Specific Requirement: Title 2 U.S. Code of Federal Regulations section 200.303 requires a nonfederal entity to establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. ● Condition: During out testing of expenses for allowability, we identified transactions where there was no evidence of being reviewed and approved by appropriate personnel for allowability. ● Corrective Action Plan: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. Financial policies and procedures will be created and implemented to ensure expenses are reviewed for allowability with federal programs.
View Audit 403049
Finding 1216528 (2024-014)
Material Weakness 2024
Pottawatomie County
OK
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.403
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
View Audit 403025
Finding 1216333 (2024-003)
Material Weakness 2024
City of Dade City
FL
Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303
Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. W...
Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. While we maintain that oversight was in place, we concur with the finding and have identified the responsibility of the process to be placed on the finance department's fiscal assistants. The lack of documented review of the reporting process is noted, and procedures are now in place for documentation of the review and approval of the data as it is reported on portals as required. The Finance Officer will direct an accountant on staff or a professional consultant to complete the preparation of the reporting so that he/she can review and authorize the submission of reports. The implementation of upgraded software and strengthened internal control policies and procedures is a priority. Anticipated Completion Date September 30, 2026 Responsible Party The Finance Officer
View Audit 402827
Finding 1216228 (2024-007)
Material Weakness 2024
Barclay College
KS
Questioned Costs Student Financial Aid Material Weakness
Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Dat...
Need Analysis Planned Corrective Action: All scholarships will be marked as estimated financial assistance and an awarding check for need will be done accurately before final distribution. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
View Audit 402736
Finding 1216225 (2024-005)
Material Weakness 2024
Barclay College
KS
Eligibility Questioned Costs Student Financial Aid
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/...
Satisfactory Academic Progress Planned Corrective Action: The SAP policy will be reviewed or created as needed and a procedure will be implemented based on that policy. Person Responsible for Corrective Action Plan: Lori Larsh, Vice President for Business Services Anticipated Date of Completion: 07/31/2026
View Audit 402736
Finding 1215998 (2024-002)
Material Weakness 2024
The Enola Group, Inc.
NC
Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Or...
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Organization submitted required reports and sought timely guidance and approvals from the federal agency, but responses were not received within the federal deadlines. These delays were outside of the Organization’s control and directly affected the timely reconciliation and finalization of reported amounts. Notably, the federal government has acknowledged delayed reports and there were no findings in their FY24 audit. Management will continue to improve internal controls and documentation practices while also documenting all federal communications and follow-up efforts to document the impact of future federal delays. PROPOSED COMPLETION DATE: Implemented and Ongoing
View Audit 402547
Finding 1215976 (2024-004)
Material Weakness 2024
JEWISH FAMILY SERVICES OF GREENWICH
CT
Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.403
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls o...
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls over all Other Than Personal Services (OTPS) expenditures. To ensure full compliance with 2 CFR 200.303 and 200.403, Finance has deployed the following enhancements to our accounts payable workflows: • Strict Electronic Approval Workflow: Finance has established a stringent review and approval protocol that requires direct involvement from Program Directors and Department Heads. All OTPS expenditures are now routed through a formalized electronic workflow, which mandates documented review and secure electronic signatures from authorized leadership prior to any payment processing. • System-Integrated Documentation: The new process strictly requires that all supporting documentation-including invoices, receipts, and evidence of allowability-be provided upfront. These documents are now uploaded and attached directly to the specific transaction within the accounting program, creating a permanent, easily accessible, and audit-ready trail for every federal charge. • Targeted Training and Oversight: To support this modernized workflow, Finance is providing targeted training to all staff responsible for initiating and approving transactions, ensuring a clear understanding of Uniform Guidance requirements. Furthermore, Finance leadership conducts periodic supervisory reviews directly within the accounting system to verify that all electronic approvals are captured and source documents are properly attached.
View Audit 402530
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