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Corrective Action Plans

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Finding 1157506 (2024-005)
Material Weakness 2024
Katy Christian Ministries
TX
Reporting Significant Deficiency Equipment & Real Property Management
Finding #2024-005 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Passed through The Houston Food Bank, Emergency Food Assistance Program – Food Commodities (Food Distribution Cluster), Assistance Listing #: 10.569, Contract ...
Finding #2024-005 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Agriculture, Passed through The Houston Food Bank, Emergency Food Assistance Program – Food Commodities (Food Distribution Cluster), Assistance Listing #: 10.569, Contract Number: 30517, Contract Year: 01/01/24 – 12/31/24. Condition and context: The adjustment reported in Finding #2024-001 to update the value of food commodities increased the Emergency Food Assistance Program (TEFAP) distributions by approximately $14,000. Additionally, the exceptions reported as finding #2024-001 included one understated receipt of 4,360 pounds TEFAP commodities. Recommendation: Same as finding #2024-001. Planned corrective action: An internal audit performed in January 2025 identified deficiencies in internal controls for the calendar year 2024, primarily due to elevated personnel turnover. In response, corrective measures were implemented in April 2025, including the establishment and documentation of formal internal controls and procedures. New management has assumed oversight responsibilities and is actively monitoring compliance to ensure sustained effectiveness of these controls. Policies and procedures over recognition of food commodities have been strengthened to ensure that the correct values for the year are used and that reconciliations are performed between the general ledger and independent worksheets used for tracking food commodities and inventory. Responsible officer: Virginia Gonzalez, Chief Executive Officer. Estimated completion date: Completed as of April 30, 2025.
View Audit 369726
Finding 1157504 (2024-002)
Material Weakness 2024
Public Health Advocates
CA
Subrecipient Monitoring Reporting
We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board mem...
We are taking immediate, multi-layered action to strengthen financial stability and restore a positive operating balance. The Board of Directors is establishing an emergency fundraising committee to raise $1 million over the next nine months. The committee is composed of current and former board members, as well as long-standing influential supporters, who have a provden ability to mobilize resources quickly. In parallel, we are convening a staff leadership committee composed of the organization's most experienced and innovative staff to design and advance high-quality proposals to private foundations, building on our strong track record of successful grant-making partnerships.
View Audit 369724
Finding 1157503 (2024-001)
Material Weakness 2024
Public Health Advocates
CA
Subrecipient Monitoring Reporting
The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that a...
The untimely completion of bank reconcilations during the audit period was due to changes in staffing and a transition to a new credit card provider, which created delays in the reconcilation process. To address this, the organization has implemented a calendar-based tracking system to ensure that all reconciliations are completed and documented promptly each month. In addition, reconcilation responsibilities have been reassigned and reinforced through updated financial procedures. Managment believes that these steps will ensure reconciliations are completed within the required timeframe moving forward and the risk of untimely reconciliations will be mitigated.
View Audit 369724
Finding 1157497 (2024-002)
Material Weakness 2024
North Pacific Fishery Management Council
OR
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties
Finding # 2025-002 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: Per Uniform Grant Guidance 200.430, charges to federal awards for salaries and wages must be based on actual work performed, supported by...
Finding # 2025-002 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: Per Uniform Grant Guidance 200.430, charges to federal awards for salaries and wages must be based on actual work performed, supported by internal controls, and part of the official records of the organization. Payroll costs charged to grants are based on estimated allocations not actual hours. All timesheets should include allocated hours by grant before certification by the employee and review by a supervisor. Corrective Action: Time sheet tracking will be modified to track hours by grant so that time and effort reporting will support amount charged to the grant. Anticipated Completion Date December 2025
View Audit 369715
Finding 1157489 (2024-001)
Material Weakness 2024
Town of Bedford
NH
Reporting Significant Deficiency Internal Control / Segregation of Duties
Re: Federal Awards Audit Finding - 2024-001 Improve Compliance with American Rescue Plan Reporting The Town agrees that expenditures were overstated on the Project and Expenditures Report for American Rescue Plan funds for the period ended March 31, 2024. Furthermore, the town acknowledges that effe...
Re: Federal Awards Audit Finding - 2024-001 Improve Compliance with American Rescue Plan Reporting The Town agrees that expenditures were overstated on the Project and Expenditures Report for American Rescue Plan funds for the period ended March 31, 2024. Furthermore, the town acknowledges that effective internal controls over federal reporting could have prevented this error. Corrective Action Plan The Town will establish and maintain effective internal control over compliance with federal requirements that have a direct and material effect on a federal program. To accomplish this, the Town will implement the practice of dual control for federal grant expenditure reporting. One individual will prepare the expenditure report, while a separate, knowledgeable individual will review the report before it is submitted. To correct the overage reported on March 31, 2024, the Town accurately reported the year-to-date expenditures on the March 31, 2025 Project and Expenditures Report, per federal guidelines. In the future, the preparer of these reports will take more care to understand the compliance requirements of the Federal awarding agency. Name of Contact and Completion Date Matt Mannino Finance Director 603-792-1313 mmannino@bedfordnh.org Anticipated Completion Date: October 31, 2025
View Audit 369711
Finding 1157485 (2024-002)
Material Weakness 2024
Ao: Advocating Opportunity, Inc.
OH
Material Weakness Reporting Internal Control / Segregation of Duties
Reporting Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure reports are prepared and reviewed by separate individuals and that the information gathered to prepare the report is retained. Explanation of di...
Reporting Services for Victims of Human Trafficking – Assistance Listing No. 16.320 Recommendation: We recommend the Organization design controls to ensure reports are prepared and reviewed by separate individuals and that the information gathered to prepare the report is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Organization has implemented a formal review process, as outlined in the board-approved Financial Management Policy & Procedure Manual, to ensure reports are prepared and reviewed by separate individuals before submission to the Federal Agency, and all supporting documentation is retained in accordance with the policy. This process is in practice as of the date of this letter, with corrective actions continuing as needed to ensure effectiveness. Name of the contact person responsible for corrective action: Megan Mattimoe, Executive Director Planned completion date for corrective action plan: December 31, 2025
View Audit 369706
Finding 1157454 (2024-004)
Material Weakness 2024
Urban Sustainability Directors Network
NC
Reporting § 200.510
The Organization acknowledges that one Federal grant was omitted from the original SEFA submitted for audit, requiring a restatement. To correct this issue, management will implement a reconciliation process that compares all grant revenue accounts and funding agreements to the draft SEFA prior to s...
The Organization acknowledges that one Federal grant was omitted from the original SEFA submitted for audit, requiring a restatement. To correct this issue, management will implement a reconciliation process that compares all grant revenue accounts and funding agreements to the draft SEFA prior to submission. The Organization will also designate a member of the finance team to perform an independent review of the SEFA for completeness and accuracy. These procedures will help ensure that all Federal awards are properly identified, included, and reported in the SEFA in future reporting periods.
View Audit 369704
Finding 1157446 (2024-004)
Material Weakness 2024
County of Luzerne, Pennsylvania
PA
Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
View Audit 369689
Finding 1157438 (2024-003)
Material Weakness 2024
County of Luzerne, Pennsylvania
PA
Reporting HUD Housing Programs Significant Deficiency § 200.303
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
View Audit 369689
Finding 1157428 (2024-004)
Material Weakness 2024
Anamosa Senior Citizens Housing INC
IA
Reporting
Recommendation: We recommend that the Corporation file the MINC reports timely. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: March 31, 2026
Recommendation: We recommend that the Corporation file the MINC reports timely. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: March 31, 2026
View Audit 369688
Finding 1157422 (2024-001)
Material Weakness 2024
Anamosa Senior Citizens Housing INC
IA
Internal Control / Segregation of Duties Reporting
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will impl...
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional controls where possible. Anticipated Date of Completion: December 31, 2025
View Audit 369688
Finding 1157418 (2024-001)
Material Weakness 2024
Christian Military Academy, Inc.
PR
Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.327
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was d...
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.
View Audit 369684
Finding 1157415 (2024-001)
Material Weakness 2024
Hale County Housing Authority
TX
HUD Housing Programs Reporting
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the nex...
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the next fiscal year.
View Audit 369677
Finding 1157413 (2024-001)
Material Weakness 2024
Spokane Valley Hub
WA
Internal Control / Segregation of Duties Reporting Significant Deficiency
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for t...
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for timely submission. We noted for two of the three reports selected; submission support was not retained by the client. The grantor confirmed submission of all required reports however, the date of submission could not be verified. As such, both reports were determined to have been submitted late. Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all quarterly reports. Calendar reminders will be added to the task list for the compiler of the report information as well as the reviewer/signer of the report. These reminders will be implemented in the work calendars of the employees responsible at the onset of the grant. Reports required by the grant must be submitted timely and must have two levels of documented review. The bookkeeper and project manager will compile the information needed for the grant. The project manager and executive director will review and sign off on the grant report prior to each reporting date. Additionally, report backup and proof of timely submission will be retained by the bookkeeper and project manager. Contact Persons: Phil Champlin – Executive Director Mary Pat Davoren – Bookkeeper
View Audit 369666
Finding 1157412 (2024-001)
Material Weakness 2024
Denver Health and Hospital Authority
CO
Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility § 200.303
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025
View Audit 369665
Finding 1157411 (2024-010)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Reporting
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. has already started the process to file the reports with HRSA to resolve this request
View Audit 369664
Finding 1157407 (2024-006)
Material Weakness 2024
Heart City Health Center, Inc.
IN
Reporting
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
View Audit 369664
Finding 1157390 (2024-003)
Material Weakness 2024
Educare of Omaha, Inc.
NE
Cash Management Eligibility Material Weakness § 200.303
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025
View Audit 369654
Finding 1157388 (2024-003)
Material Weakness 2024
Lincoln County, Nebraska
NE
Reporting Internal Control / Segregation of Duties
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
View Audit 369653
Finding 1157386 (2024-007)
Material Weakness 2024
Northwest Side Housing Center
IL
Reporting Matching / Level of Effort / Earmarking § 200.510
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
View Audit 369652
Finding 1157385 (2024-006)
Material Weakness 2024
Northwest Side Housing Center
IL
Cash Management Reporting Internal Control / Segregation of Duties
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
View Audit 369652
Finding 1157375 (2024-004)
Material Weakness 2024
Northwest Side Housing Center
IL
Cash Management Reporting
The Center is implementing reconciliations of the grant expenditures to the general ledger.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
View Audit 369652
Finding 1157366 (2024-004)
Material Weakness 2024
Keystone Restituere Justice Center, Inc.
PA
Reporting § 200.328
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timefr...
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timeframes. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: KRJC has now developed a clear procedure for ensuring that all program expenses are received and/or accrued for the period so that reporting can be completed and submitted no later than 30 days after the end of the quarter. All FFY2025 required financial and narrative reporting has been submitted within the required time frame. Planned completion date for corrective action plan: November 30, 2024.
View Audit 369651
Finding 1157341 (2024-001)
Material Weakness 2024
Journey's End Refugee Services, Inc.
NY
Procurement, Suspension & Debarment Subrecipient Monitoring Reporting
Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific n...
Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific noncompliance identified by the auditor.) Failure to Submit monthly financial reports by the 15th of each month following, resulting in noncompliance with grant agreement. 2. Root Cause (Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls.) Lack of process, including a tracking mechanism that identifies due dates and completion dates of all reports due. 3. Corrective Actions: A) Create a report in excel to track grant reports deadlines. B) Weekly review of the report by the Grants and Finance committee. C) Purchase and implementation of grants monitoring software. 4. Monitoring Plan (Describe how the implementation of corrective actions will be monitored and evaluated.) New Chief Financial Officer will review the action items and monitor the progress with the Chief Operating Officer monthly.
View Audit 369618
Finding 1157324 (2024-002)
Material Weakness 2024
201 Thurbers Inc.
RI
Reporting Internal Control / Segregation of Duties
Security Deposit Funding Auditee agrees that the security deposit liability account is underfunded. We recommend that management funds the shortfall and created a better system of controls to ensure no future occurrences. Auditee plans to evaluate its internal controls and implement policies to miti...
Security Deposit Funding Auditee agrees that the security deposit liability account is underfunded. We recommend that management funds the shortfall and created a better system of controls to ensure no future occurrences. Auditee plans to evaluate its internal controls and implement policies to mitigate underfunding of the security deposit account and has funded the shortfall. Transfer of $1,271 to security deposit account was made to fully fund the account.
View Audit 369605
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