Corrective Action Plans

Finding 1166605 (2023-004)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Questioned Costs Reporting Significant Deficiency § 200.512

2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; ...

2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Coronavirus State and Local Fiscal Recovery ALN 21.027; passed through the Commonwealth of Pennsylvania Department of Community and Economic Development. Condition The Authority did not submit the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse within the required timeframe of nine months after the end of the audit period. The 2022 reporting package was submitted on May 7, 2025, which was after the one month due date of September 30, 2023. In addition, the 2023 reporting package was not submitted by the September 30, 2024 due date. Recommendation We recommend that the Authority continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse. Management Response The Authority will continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse.

View Audit 377585

Finding 1166599 (2023-003)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.400

2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on f...

2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.

View Audit 377585

Finding 1166598 (2023-002)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Questioned Costs Material Weakness Reporting § 200.307

2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income ...

2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.

View Audit 377585

Finding 1166594 (2023-001)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

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

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.

View Audit 377585

Finding 1166493 (2023-008)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Cash Management Reporting § 200.327 § 200.328

Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the fi...

Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the findings; Responsible Individual: Nicole Reinert, Public Health Director; Corrective Action Plan: Administrative staff will schedule out all required report dates in the Outlook calendar at least three weeks before the due date to keep responsible parties informed of deadlines. These set reminders will ensure timely submissions. The Department Head will review the submission process to eliminate congested workflow to ensure efficiency and identify any tasks that can be automated or improved. Regular check-ins will take place to discuss the status of ongoing reports.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166491 (2023-006)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Eligibility Reporting § 200.328

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Manageme...

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Certification Title III Expenditures and Unobligated Funds by statutory deadline. This process should include clear assignment to responsibilities and retention of documentation as part of grant compliance records.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166325 (2023-009)

Material Weakness 2023

Dorchester County, Maryland

MD

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

The County will implement procedures to ensure the review and approval of the monthly report is documented.

View Audit 377392

Finding 1166286 (2023-003)

Material Weakness 2023

Hill Country Community Clinic, Inc.

CA

Cash Management Questioned Costs

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.

View Audit 377361

Finding 1166285 (2023-002)

Material Weakness 2023

Hill Country Community Clinic, Inc.

CA

Questioned Costs Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 377361

Finding 1166216 (2023-002)

Material Weakness 2023

Fayette County General Health District

OH

Allowable Costs / Cost Principles Questioned Costs § 200.430

Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3%...

Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.

View Audit 377197

Finding 1166097 (2023-006)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025

View Audit 376863

Finding 1166078 (2023-003)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles Questioned Costs Material Weakness

Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Depa...

Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Department to address this finding. The context below is from CD: Corrective action implemented with City FY24 (07/01/23-06/30/24). Annually, a budget for staff salary and fringe is developed and approved by CD Director Marsh. The annual budget details staff hours and cost centers each will be charged during the year ( e.g. CDBG activity delivery, CDBG admin, Seaport Marina, Auditorium, ESG, etc.). Additionally, employees track time on individual time sheets weekly. This finding was also noted at the last HUD monitoring review, and marked as resolved and closed in June 2024 following HUD's post review. Name of Contact Person and Completion Date James Marsh, Executive Director of The Office of Community Development & Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1166069 (2023-002)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles School Nutrition Programs Questioned Costs

Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...

Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025

View Audit 376863

Finding 1166049 (2023-001)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles School Nutrition Programs Questioned Costs

Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressin...

Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressing that this is a finding and more diligence needs to occur in order to remove this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025

View Audit 376863

Finding 1165780 (2023-002)

Material Weakness 2023

City of Springfield

OH

Questioned Costs Subrecipient Monitoring Reporting

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training...

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training to staff on SLFRF reporting requirements and deadlines, implement written policies and procedures to ensure timely submission of all reports, including establishing a compliance calendar with automated reminders and maintaining a reporting log to track submission dates. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Katie Eviston, Finance Director, (937) 324-7700

View Audit 376568

Finding 1164722 (2023-003)

Material Weakness 2023

Chrysalis Center

CA

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties § 200.302 § 200.403 § 200.430

Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal proce...

Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal process for preparation of the SEFA. Recommendation: Management should prepare a master tracking schedule for government grants which includes the source of funding and audit and reporting requirements. The schedule should be prepared by someone with knowledge of the grant agreements and reviewed by a leader in the accounting department to ensure completeness. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management has implemented a master tracking schedule for government grants that includes the source of funding and audit and reporting requirements. This tracker is a joint effort between finance and grants management teams. Anticipated Completion Date: December 31, 2025

View Audit 374440

Finding 1164633 (2023-003)

Material Weakness 2023

Net Treatment Services, Inc. D/b/a Net Community Care

PA

Questioned Costs Student Financial Aid Cash Management

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: J...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: July 1, 2022 through June 30, 2023 Type of Finding: Material Weakness in Internal Control over Compliance and Cash Management Recommendation: We recommend that management ensure that all invoices are based on actual expenses incurred and that there is a review an approval process of invoices before submission. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Aciton take in response to finding: Management has implemented a policy which requires each invoice to be based only on actual expenses incurred for the period and prohibits the use of a straight-line calculation to draw down funds. Invoices are also approved by the CFO prior to submission for reimbursement. Name of contact person responsible for corrective action: Regan Kelly, CEO of NorthEast Treatment Cetners, Inc. (215) 451-7000 Planned completion date for corrective action plan: January 31, 2024

View Audit 374235 Questioned Costs: $1

Finding 1164572 (2023-001)

Material Weakness 2023

Strategic Capacity Group, Inc.

VA

Questioned Costs

STRATEGIC CAPACITY GROUP CORRECTIVE ACTION PLAN For the Year Ended December 31, 2023 U.S. DEPARTMENT OF STATE Strategic Capacity Group (SCG) submits the following corrective action plan for the year ended December 31, 2023. Independent Public Accounting Firm: CBIZ CPAs P.C. 1899 L Street NW, Suite 8...

STRATEGIC CAPACITY GROUP CORRECTIVE ACTION PLAN For the Year Ended December 31, 2023 U.S. DEPARTMENT OF STATE Strategic Capacity Group (SCG) submits the following corrective action plan for the year ended December 31, 2023. Independent Public Accounting Firm: CBIZ CPAs P.C. 1899 L Street NW, Suite 850 Washington, DC 20036 Audit Period: The finding from the December 31, 2023 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDING - FINANCIAL STATEMENT FINDINGS Finding No. 2023-001: Late Filing of Data Collection Form – Compliance Finding – All Federal Awards Criteria In accordance with the Uniform Guidance, the audit package and the Data Collection Form must be submitted within 30 days after receipt of the auditors’ report or nine months after the end of the fiscal year, whichever comes first. Condition and Context The Data Collection Form for the year ended December 31, 2023 was not submitted to the Federal Audit Clearinghouse by the September 30, 2024 deadline. Recommendation It was recommended that management continue its efforts to ensure that all filing requirements under federal awards are met. Views of Responsible Officials and Planned Corrective Actions SCG has consistently ensured that all audits preceding fiscal year 2023 were completed by the annual September 30 deadline. As this was a singular occurrence arising from SCG’s appeal to the U.S. Department of State on December 20, 2023 concerning differing interpretations surrounding the configuration and application of the Negotiated Indirect Cost Rate Agreement (NICRA), SCG believes no corrective action is warranted. SCG received a response to its appeal only on September 24, 2024. Had it not been for this unique circumstance and the timing of the U.S. Department of State’s appeal determination, SCG’s 2023 audit would have been completed and submitted by the required deadline of September 30, 2024. Contact Person Responsible for Corrective Action: Querine Hanlon, President _______________ If the US Department of State has questions regarding this plan, please call Querine Hanlon, President, (202) 746-7317. Sincerely, Querine Hanlon President Strategic Capacity Group

View Audit 374156

Finding 1164330 (2023-001)

Material Weakness 2023

JXN Water

MS

Internal Control / Segregation of Duties Questioned Costs

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

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

View Audit 373772

Finding 1163490 (2023-002)

Material Weakness 2023

State of Kosrae

FM

Questioned Costs Procurement, Suspension & Debarment

Finding No. 2023-002 Area: Procurement, Suspension and Debarment Views of Auditee and Planned Corrective Action: We agree with this finding. The administering departments will strengthen their procedures for verifying the suspension and debarment status of vendors by (1) checking ‘SAM.gov exclusions...

Finding No. 2023-002 Area: Procurement, Suspension and Debarment Views of Auditee and Planned Corrective Action: We agree with this finding. The administering departments will strengthen their procedures for verifying the suspension and debarment status of vendors by (1) checking ‘SAM.gov exclusions” and (2) attaching to the purchase requisition a printout of the appropriate page from the SAM Exclusion website. Anticipated Completion Date: Ongoing Name of Contact Person: Ms. Lona Lyndon Esau Administrator, Office of Finance Department of Administration and Finance Email: alomalya.dofa@gmail.com

View Audit 373101 Questioned Costs: $1

Finding 1163482 (2023-001)

Material Weakness 2023

State of Kosrae

FM

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs

Finding No. 2023-001 Area: Allowable Costs/Cost Principles Views of Auditee and Planned Corrective Action: We agree with this finding and the department will have to seek available funds from our State General Funds to settle this. Unfortunately, this was an expenditure passed two fiscal years, I ca...

Finding No. 2023-001 Area: Allowable Costs/Cost Principles Views of Auditee and Planned Corrective Action: We agree with this finding and the department will have to seek available funds from our State General Funds to settle this. Unfortunately, this was an expenditure passed two fiscal years, I can only admit that the payment process sounded acceptable due to the urgency of the situation at that time; however, now that we have realized that Sector money used to bring the students back was inappropriate and should not have been allowed, we regretfully have to admit our failure and seek solutions to settle this appropriately. In line with the findings, the department of education management is looking into this with the Kosrae State Scholarship Board and agree to formulate a new disbursement policy with Sector student scholarship awards. This new disbursement policy with sector student scholarship will have all student scholarship routed thru Kosrae Department of Education Director’s office for his or his designee for compliance. The department will also strengthen it’s internal control by verifying terms and conditions specified in the Compact grant awards before we proceed with the fund disbursement. Anticipated Completion Date: Ongoing Name of Contact Person: Mr. Tulensru Waguk Director Department of Education Email: twaguk@kosrae.doe.fm

View Audit 373101 Questioned Costs: $1

Finding 1163398 (2023-003)

Material Weakness 2023

CUMAC/ECHO, Inc.

NJ

Reporting Questioned Costs Allowable Costs / Cost Principles

Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with U...

Finding --- The Organization does not consistently reconcile its quarterly financial reports submitted to governmental agencies to the general ledger by grant program. Corrective action – Management will develop and implement written procedures to improve their reporting process in accordance with Uniform Guidance and New Jersey 15-08-OMB. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07505

View Audit 372936

Finding 1163374 (2023-002)

Material Weakness 2023

Mitchell County Hospital District

TX

Allowable Costs / Cost Principles Questioned Costs Reporting

The District has adopted a Federal Grant Reporting Policy requiring all submissions to federal or state agencies to include complete supporting documentation retained for at least seven years. A standardized Lost Revenue Calculation Template has been created to document methodology, source data, and...

The District has adopted a Federal Grant Reporting Policy requiring all submissions to federal or state agencies to include complete supporting documentation retained for at least seven years. A standardized Lost Revenue Calculation Template has been created to document methodology, source data, and reconciliations to general ledger balances. The CFO will ensure all future PRF and grant reports undergo a dual review and sign-off process prior to submission. Historical data for Period 4 PRF reporting has been reconstructed from audited financial records, and the District has verified that lost revenues during the eligible reporting period exceed the total PRF funds retained, demonstrating that all funds were appropriately supported from a financial standpoint. While the original internal calculation did not agree to the exact amounts reported to HRSA, the District’s current analysis and documentation substantiate the PRF funds in accordance with HRSA’s intent and guidance. Staff have completed Uniform Guidance and HRSA PRF compliance training to ensure future submissions include all required support and reconciliation. Target Completion November 30, 2025. Responsible Official: Diane Moore, Chief Financial Officer.

View Audit 372891

Finding 1163333 (2023-006)

Material Weakness 2023

State of Kosrae

FM

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs

Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there ...

Finding 2023-006: This is for Special Education Condition 1: For 4 of the transactions total question costs $512. The supporting documentations were not provided. Conditional 2: No departmental timecards or timesheets were provided to support compensation. Condition 3. Payroll with timecards, there were no verification performed at the departments to ensure that what is being paid are correct. Root Cause Analysis a. Condition 1: Ineffective documentation retention at treasury, exacerbated by office relocation. b. Condition 2: Ineffective retention at departmental agencies where timesheets are held. c. Conditions 3(a) and 3(c): Weak internal controls over reconciliation between departmental timesheets and treasury uniform timesheets. Treasury does not regularly obtain departmental timesheets. d. Condition 3(b): Manual timecard errors from daily stamp-based systems. Corrective Actions 1. Strengthen documentation retention controls. 2. Enhance monitoring at the departmental level or implement a uniform timekeeping system to reduce reconciliation issues. 3. Require submission of departmental timekeeping reports to treasury for secondary reconciliation. 4. Ensure explanatory documentation is retained when uniform timesheets differ from departmental records. Responsible Parties For CAP 1. Director of DOTA and Payroll division For CAP 2. Special Education Administrator and his timekeepers For CAP 3. Director of DOTA and Payroll division For CAP 4. Both Department of DOTA and Special Ed Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.

View Audit 372843 Questioned Costs: $1

Finding 1163327 (2023-003)

Material Weakness 2023

State of Kosrae

FM

Questioned Costs Procurement, Suspension & Debarment § 200.318 § 200.319 § 200.320

Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procuremen...

Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procurement selection. • For test no. 16, obligation 372216 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 17, obligation 372215 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 22, obligation 334914 – The procurement file included 2 quotations and a justification form that did not relate to the transaction as it cites an explanation for purchasing goods from other vendors unrelated to the actual transaction. Of the 2 vendors included, there did not appear to be a notable difference in goods/services offered, however the higher of the 2 was selected. Consequently, we could not determine the ultimate basis for vendor selection. • For test no. 30, obligation 358537 – The procurement as sourced from one vendor and lacks additional quotations. There was no documented justification for the sole-source procurement. Root Cause Analysis Ineffective documentation filing and retention controls, further impacted by the relocation of the State Treasury office. Corrective Actions • Strengthen procurement documentation controls and ensure rationales and justifications for vendor selection are retained in procurement files. Responsible Parties Director of Education and its administrative officers Director of Health and administrative officers Director of DOTA, certification and payable section Timeline Verification of Effectiveness Periodically verify the department's purchases to ensure that no instances of noncompliance are still taking place.

View Audit 372843 Questioned Costs: $1

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