Corrective Action Plans

Finding 1172271 (2024-006)

Material Weakness 2024

OR

Subrecipient Monitoring Procurement, Suspension & Debarment Material Weakness § 200.301 § 200.328 § 200.329 § 200.334

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environ...

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of AgricultureFederal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Under 2 CFR 200, recipients must submit performance and financial reports as required by the terms and conditions of the award and must retain records sufficient to demonstrate compliance (see (§200.301Monitoring and reporting program performance, and §200.328 Financial reporting, §200.329 Monitoring and reporting program performance, and §200.334 Retention requirements for records). The grant agreements for awards above require timely submission of performance / progress reports by specified due dates, with documentation maintained to support the submitted information. Condition: For the fiscal year ended June 30, 2024, the auditee could not provide sufficient evidence that required reports for the programs listed were prepared, reviewed, and submitted in accordance with grant terms. Specifically:  No provided required financial reports, and Partnership for the Umpqua Rivers lacked copies or evidence of submission, and support for reported amounts requested.  Auditors were not provided with performance/progress reports and were instructed that Partnership for the Umpqua Rivers had no retained copies, review sign-offs, or submission confirmation.  Where payments were received, support for the required reports or metrics were not retained and could not be supplied to auditors for reconciling to underlying records. Cause: Management has not implemented formal reporting controls, including:  A documented reporting calendar with due dates and responsible staff,  Reconciliation of report amounts to the accounting records,  Retention procedures for report copies, underlying support, and submission confirmations, and  Supervisory review evidenced by signatures or workflow approvals. Effect or Potential Effect: Absent evidence of timely, accurate reporting and adequate record retention:  The organization is at risk of noncompliance with federal award conditions,  Inaccurate financial or performance information may be reported to the funding agency, and  The entity may be subject to remedial actions, including heightened monitoring, repayment of questioned amounts, or potential suspension of funding. Questioned Cost: None directly noted, but potential risk if reports were incomplete or inaccurate.Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. Award files provided to auditors did not contain information related to reporting of activity, expenditures, or progress of the awards. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Establish a formal reporting and retention policy aligned with 2 CFR 200 and grant terms.  Implement a centralized reporting calendar that tracks due dates, preparers, reviewers, and submission methods.  Require reconciliations of financial reports to the general ledger and supporting schedules, retain the reconciliation with the reporting package.  Create standard workpapers for performance metrics for each award.  Configure the grant portal or document management system to retain submission confirmations, reports, receipts, and version -controlled copies of all reports for awards.  Document supervisory review through sign-offs prior to submission and with evidence retained.  Provide training to staff on Uniform Guidance requirements and record retention (§200.334). District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: ____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _____________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172217 (2024-004)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.302 § 200.303

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Env...

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land ManagementCriteria: Under Uniform Guidance 2 CFR §200.303, non-federal entities must establish and maintain effective internal control over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the award terms and conditions. This includes ensuring that:  Personnel administering federal awards possess adequate skills, knowledge, and experience.  Management and leadership provide appropriate oversight of federal award activities.  Financial management systems adequately support accurate reporting, documentation, retention, and reconciliation of federal expenditures in accordance with 2 CFR §200.302. Condition: During the audit of federal awards, the entity did not demonstrate sufficient skills, knowledge, or experience of the staff and leadership responsible for administering and overseeing federal programs. Specifically:  Adequate supporting documentation for federal award expenditures was not maintained or provided.  Leadership oversight of federal award compliance activities was limited, and management review of grant activity were not evidenced. These conditions resulted in weaknesses in financial reporting, compliance monitoring, and documentation related to federal awards. Cause: Partnership for the Umpqua Rivers has not ensured that staffing levels, qualifications, and experience are sufficient to support federal award administration and compliance. In addition, leadership lacks adequate knowledge of federal award requirements to provide effective governance, oversight, and monitoring of compliance activities. Formal training and documented procedures for federal awards management have not been prioritized. Effect or Potential Effect: As a result of these deficiencies:  Partnership for the Umpqua Rivers is at increased risk of non-compliance with Uniform Guidance requirements.  Federal expenditures may be unsupported, inaccurately reported, or unallowable.  Errors or compliance violations may not be detected or corrected in a timely manner.  The entity may be subject to questioned costs, repayment of federal funds, or additional scrutiny from grantor agencies. Questioned Cost: None identified Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Ensure staff responsible for federal awards receive appropriate training on Uniform Guidance requirements, grant financial management, documentation, and compliance monitoring. Assign federal award oversight to personnel with sufficient experience and qualification or obtain external grant management and accounting support as needed.  Establish written policies and procedures for federal award administration, including expenditure documentation, reconciliation, compliance review, and management approvals.  Require leadership to perform and document periodic oversight and monitoring of federal awards, including review of reconciliations reimbursement requests, and compliance metrics.  Implement ongoing monitoring and internal control assessments to ensure compliance with federal award requirements. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: ___________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172190 (2024-003)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Reporting Subrecipient Monitoring § 200.302 § 200.303 § 200.430

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Enviro...

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation ServiceName of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Title 2 CFR §200.303 requires nonfederal entities to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing the awards in compliance with federal statutes, regulations, and the terms and conditions of the award. Additionally, 2 CFR §200.302(b)(3) requires entities to maintain records that adequately identify the source and application of funds, including supporting documentation for expenditures, and 2 CFR §200.430 requires documentation for compensation for personal services. Condition: During our review of expenditures charged to the federal programs, the entity was unable to provide invoice copies or other sufficient supporting documentation for certain expenditures tested. As a result, we could not verify the allowability, accuracy, and proper approval of these costs in accordance with federal requirements. In addition, records were unavailable for Personnel expenditures that were charged to grant awards, and no support or evidence of time per grant was available. Cause: Partnership for the Umpqua Rivers does not have effective internal controls in place to ensure that invoice documentation and other supporting records are retained, centrally filed, and readily available for audit and monitoring purposes. In addition, management did not perform ongoing monitoring to verify that required documentation was maintained prior to reimbursement or reporting. Effect or Potential Effect: because supporting documentation was not available, expenditures from detail documentation could not be substantiated. This increases the risk that the unallowable, unsupported, or inaccurate costs may be charged to the federal program and reported in the Schedule of Expenditures of Federal Awards (SEFA). Questioned Cost: Yes, $332,409 related to Personnel costs, equipment and other purchases that were not documented with detailed support. Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit.Recommendation: Partnership for the Umpqua Rivers should implement policies and procedures requiring invoice copies and supporting documentation to be maintained for all grant expenditures. Management should strengthen record retention practices, provide training to staff on documentation requirements, and implement periodic internal reviews to ensure compliance. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172106 (2024-001)

Material Weakness 2024

Coordinated Behavioral Care

NY

Reporting Significant Deficiency § 200.512

Management remains committed to full compliance with federal reporting requirements. Once all outstanding filings are brought up to date, we will ensure that future submissions are completed within the required deadlines.

View Audit 385259

Finding 1172086 (2024-006)

Material Weakness 2024

Housing Authority of the City of Conway

AR

Subrecipient Monitoring HUD Housing Programs Reporting

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address mis...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address missing self-certification documentalion to ensure compliance. The Authority must take immediate steps to remediate these deficiencies by establishing a robust, auditable documentation process: • Strengthen Internal Controls: Develop procedures to ensure complete and accurate documentation is maintained for all 14 SEMAP indicators, including detailed sampling methodologies. • Pre-Certification Review: Implement a mandatory management review process for all SEMAP documentation before final certification is submitted to HUD. • Ensure Proper Retention: Enforce document retention policies that align with HUD regulations, ensuring records are accessible for audit purposes. • Staff Training: Provide training to staff regarding SEMAP indicator requirements and the necessity of maintaining supporting evidence. • Utilize PIG Reports: Ensure all tenant data is properly reported in PlC, as this is the basis for several indicators. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Most of the corrective activities are completed. We anticipate completing the balance of activities by May 1, 2026.

View Audit 385225

Finding 1172059 (2024-001)

Material Weakness 2024

Greater Baltimore Medical Center, INC

MD

Reporting

Management will strengthen internal controls over the reporting of expenditures on the schedule of expenditures of federal awards (SEFA) to ensure it is complete and accurate. The Company will provide additional training to staff to better understand the importance of the reporting requirements and ...

Management will strengthen internal controls over the reporting of expenditures on the schedule of expenditures of federal awards (SEFA) to ensure it is complete and accurate. The Company will provide additional training to staff to better understand the importance of the reporting requirements and how to properly record federal awards in the general ledger. Management will work directly with the accounting and grants departments when the Company receives new awards to ensure that all award information is reviewed appropriately to determine if it is a federal award.

View Audit 385185

Finding 1171959 (2024-003)

Material Weakness 2024

Galveston County Health District

TX

Allowable Costs / Cost Principles Cash Management Material Weakness

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper...

Finding: 2024-003 Material Weakness in Internal Control Over Allowable Costs/Cost Principles and Reporting – WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (10.557, 93.268) Corrective Action: We will work to ensure that the proper indirect cost rate is applied to the various grants. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171958 (2024-002)

Material Weakness 2024

Galveston County Health District

TX

Reporting Material Weakness Period of Performance

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process ...

Finding: 2024-002 Material Weakness in Internal Control Over Period of Performance – Health Center Program, WIC Special Supplemental Nutrition Program for Women, Infants, and Children, and Immunization Cooperative Agreements (93.224, 10.557, 93.268) Corrective Action: The District is in the process of developing a comprehensive year-end closing checklist and has already streamlined many of the procedures that caused reconciliation issues. In addition, we will perform spot checks on transactions to ensure that payroll and nonpayroll expenditures are recorded in the proper period. We will also provide additional training to ensure that personnel only record expenditures when confirmation has been received of receipt of goods or services. Proposed Completion Date: February 28, 2026 Name of Contact Person: Tomiko Fisher, Chief Operating Officer

View Audit 385024

Finding 1171942 (2024-002)

Material Weakness 2024

City of Williamsport

PA

Reporting

Finding 2024-002 Reporting Corrective Action: The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected with 2025 reporting.

View Audit 385019

Finding 1171931 (2024-004)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties

Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated ﬁnancial policies, reﬂecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director wi...

Planned Corrective Action: SAVA Center’s new Executive Director added information about the requirements for a single audit to the newly updated ﬁnancial policies, reﬂecting that it is the responsibility of the Executive Director to monitor when a single audit is warranted. The Executive Director will maintain a spreadsheet summarizing the Schedule of Federal Expenditures (SEFA) and provide this to the auditor engaged to perform the Single Audit. Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 12, 2026

View Audit 384965

Finding 1171924 (2024-010)

Material Weakness 2024

Community Benefit Solutions

PA

Procurement, Suspension & Debarment School Nutrition Programs Internal Control / Segregation of Duties

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on interviews by the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (“Commonwealth”) with CBS Food program management, inspection of records, and on-site observations, we identified internal control deficiencies in the following areas: • For a portion of the audit period, there was a lack of segregation of duties between the cash receipt, bookkeeping, and bank reconciliation processes. The Director of Finance was responsible for all these tasks. The Director of Finance was also responsible for both processing and approving payroll and had authorization to make purchases, make vendor payments, record accounting transactions and complete bank reconciliations. • CBS Food Program performs bank reconciliations; however, they are not signed or dated by the individual performing the reconciliation and a second individual does not review or sign off on the reconciliations. Of nine reviewed account reconciliations, three were completed more than 30 days after the statement period end date. • According to CBS Food Program's former Purchasing Distribution Manager, as of June 2024, they were the only CBS Food Program's employees with detailed knowledge of developing monthly menus and creating purchase orders based on current inventory levels to meet menu requirements. Additionally, the former Purchasing Distribution Manager stated that as of June 2024 formal training on internal purchasing policies and procedures is not provided or required. Condition (Continued) • For a portion of the engagement period, CBS Food Program lacked written policies or procedures for several key business functions including: o No written Accounting Manual or Standard Operating Manual for accounting functions. o No written policy or procedure for the use of credit cards or the handling of lost or stolen credit cards. o No written policy or procedure to analyze account balances to ensure transactions have been properly recorded. o No written records retention policy. o No written procedures for handling payroll for separating employees. o No written or implemented review process for changes to the payroll system including changes to employee payrates. o For a portion of the engagement period, the Food Program did not have procedures to o Prior to July 1, 2024, CBS Food Program did not have documented procurement procedures. On July 1, 2024, CBS Food Program implemented a procurement plan. Recommendation: If not already addressed, CBS Food Program should develop and implement improved internal controls including: • Develop written policies, procedures and/or manuals for accounting functions. • Develop a formal internal control policy and framework that focuses on key business and operations areas including segregation of duties, transaction review and approval processes, and monitoring procedures over critical operational functions. • Improve cross training of employees including training on purchasing and accounting tasks. • CBS Food Program should develop and implement a record retention policy that complies with food program requirements for maintaining documentation of operations. The policy should ensure key records are maintained in a shared location accessible to all appropriate personnel. This ensures the CBS Food Program does not lose access to key records in the event an employee leaves the food program. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions will work with its outside independent audit firm, Board-approved counsel, and other necessary stakeholders to develop and implement all the necessary controls as required by the Comptroller. Community Benefit Solutions' implementation of any of the noted changes will be the ability to recruit Finance Committee and Nutrition Committee members of the Board. Moreover, Community Benefit Solutions made strides in implementing some of the requested policies during the Audit. Community Benefit Solutions will endeavor to meet each of the requests despite any lack of human capital that would allow for ease of segregation of authority. Community Benefit Solutions is optimistic that incoming Board Members and external accounting, audit, HR, and legal will provide critical support. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171914 (2024-008)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Subrecipient Monitoring Material Weakness § 200.327 § 200.328 § 200.334

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirem...

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirements for the CBS Food Program under the National School Lunch Program (NSLP) and Summer Food Service Program (SFSP), management is responsible for submitting the FNS 10 (NSLP) and FNS 418 (SFSP) reports within 30 days after month-end. However, management was unable to provide five (5) monthly NSLP reports and one (1) monthly SFSP report requested for audit testing. Recommendation: The Organization should establish and enforce strengthened internal controls over federal reporting to ensure that all required monthly reports (FNS 10 and FNS 418) are: (a) completed accurately, (b) submitted on time, and (c) retained in accordance with federal record retention requirements (2 CFR 200.334). Management should designate responsible personnel and implement a monitoring process to ensure compliance. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Effective, July 1, 2024, Community Benefit Solutions no longer administers the National School Lunch Program. In the event Community Benefit Solutions should begin administering the NSLP, Community Benefit Solutions will develop and implement requisite policies and procedures to ensure proper reporting requirements including, but not limited to, completion and submission of the FNS10. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171899 (2024-003)

Material Weakness 2024

City of Gloversville, New York

NY

Reporting Internal Control / Segregation of Duties § 200.510

The City will implement procedures to ensure accurate SEFA preparation

View Audit 384938

Finding 1171869 (2024-006)

Material Weakness 2024

Municipality of Loiza

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.339

The Municipality Administration is currently addressing the control and compliance issue. Starting on January 2026 prior year reports will be submitted. Full compliance expected to start on January 2026 going forward.

View Audit 384837

Finding 1171868 (2024-005)

Material Weakness 2024

Municipality of Loiza

PR

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.339

All monthly reports were delivered on time to AFAAF as established on the guidelines and following the agency’s reporting guidelines and support. The Municipality is full compliance with the Puerto Rico Fiscal Agency and Financial and Financial Advisory Authority

View Audit 384837

Finding 1171867 (2024-004)

Material Weakness 2024

Municipality of Loiza

PR

Reporting Significant Deficiency § 200.12 § 200.508 § 200.510 § 200.512

The Municipality is working diligently to publish its statements on time. In 2025 the Municipality published two audited statements (2022 and 2023) and the 2024 audited statements are expected to be published in January 2026. The 2025 audited financial statements will be published on time.

View Audit 384837

Finding 1171851 (2024-001)

Material Weakness 2024

Horizon Healthcare Partners

RI

Internal Control / Segregation of Duties Reporting

We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assu...

We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assumptions about major Federal program compliance requirements for fiscal 2019, 2020, 2021, 2022, 2023, and 2024 management failed to provide for timely audits. One critical assumption was that the Organization’s subrecipient, responsible for over ninety percent (90%) of grant distributions, fulfilled the audit requirement for the required Federal grant reporting under the Single Audit Act. However, upon recognizing this error, the Organization promptly engaged for the financial statement and major Federal program compliance audits spanning multiple years including up to last fiscal year and is on track to provide for timely filing with the current year. With this understanding and the expectation of financial statement and major Federal program compliance audits, the Organization replaced its contracted accountants by hiring its first Chief Financial Officer (CFO) in January of 2021 and a number of additional support accountants beginning in November of 2021 through January of 2024. Upon hire, and with the growth of the programming, the CFO and the accounting team focused extensively on enhancing the Organization’s financial reporting framework and data management systems to ensure continued compliance with federal and state guidelines and reporting requirements. This effort has been crucial in expediting the more recent audits and improving overall efficiencies in the day-to-day and monthly financial reporting and budgeting requirements. Further, the Organization must acknowledge the challenges posed by the transition of multiple Chief Executive Officers in a 2-year period as well as the impact of the pandemic on operations and reporting. These two factors affected operations and time lines as well as access to data files as many were in paper form. Despite these difficulties, management’s commitment to timely financial reporting and program compliance remains steadfast and are working diligently to get its timing back on track going forward.

View Audit 384813

Finding 1171705 (2024-012)

Material Weakness 2024

Osage County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk's administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to up...

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk's administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to update procedures and build stronger internal controls, • developing and formalizing policies to ensure full compliance with federal grant requirements, • and improving communication between offices to ensure federal reporting is accurate and timely. Our collective commitment is to put permanent measures in place to prevent these issues from recurring and to uphold the highest level of compliance for all federal programs. County Clerk: I was not the County Clerk in office at this time. The County will comply with all aspects of grant reporting and requirements. The Officials will work together to put policies and procedures in place to ensure more accurate reporting. County Treasurer: The County Officers will work on better communication to more accurately report the SEFA funds.

View Audit 384731

Finding 1171704 (2024-011)

Material Weakness 2024

Osage County

OK

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior County Clerk's administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of...

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior County Clerk's administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County Commissioners, the new County Clerk and the other elected officials have made addressing these control weaknesses a priority. Together, we are: • strengthening county-wide policies and procedures to meet federal compliance requirements • improving communication and oversight to ensure accurate and timely federal reporting • and establishing clear standards and training for all reporting officers to prevent inaccurate or untimely reporting. Our collective goal is to build a stronger, more accountable system that ensures federal programs are managed with the highest level of integrity. County Clerk: I was not the County Clerk in office at this time. Ensure that the County has standards in place that will deter inaccurate and untimely reporting. In addition, those reporting have the knowledge and understanding to properly report. County Treasurer: The County Officers will work on better communication to more accurately report the Schedule of Expenditures of Federal Awards (SEFA) funds.

View Audit 384731

Finding 1171374 (2024-003)

Material Weakness 2024

Williamson Health and Wellness Center, Inc.

WV

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation: We recommend that the Center implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting and assigning responsibility...

Recommendation: We recommend that the Center implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting and assigning responsibility for tracking and ensuring timely submission of reports. Views of responsible officials and planned corrective actions: Management agrees with the recommendations. Management will implement appropriate internal control procedures. Anticipated Completion Date: January 31, 2026.

View Audit 384660

Finding 1171331 (2024-002)

Material Weakness 2024

City of Bayonne

NJ

Reporting § 200.328

The City will assign responsibillity for the filing of the Federal Financial Reports and will verify that the reports have been submitted.

View Audit 384607

Finding 1171102 (2024-002)

Material Weakness 2024

CITY OF ROSE CITY, TEXAS

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

The City of Rose City, Texas’s Council has reviewed the findings indicated as 2024-001 and 2024-002 and agree with the findings. The Council adopted controls to ensure that the City will comply in all material respects with its reporting requirements as per the Texas Local Government Code and the Un...

The City of Rose City, Texas’s Council has reviewed the findings indicated as 2024-001 and 2024-002 and agree with the findings. The Council adopted controls to ensure that the City will comply in all material respects with its reporting requirements as per the Texas Local Government Code and the Uniform Guidance 2 CFR 200. In addition, the Council has further involved the outside independent accounting firm to assist the City in its accounting and monitoring activities.

View Audit 384497

Finding 1171085 (2024-001)

Material Weakness 2024

Kootenai County Water District No. 1

ID

Reporting Eligibility § 200.512

The District acknowledges that the fiscal year 2024 Single Audit was not completed within the nine-month deadline. Fiscal year 2024 was the District’s first year meeting the expenditure threshold requiring a Single Audit, and staff were not previously aware that the Single Audit shared the same nine...

The District acknowledges that the fiscal year 2024 Single Audit was not completed within the nine-month deadline. Fiscal year 2024 was the District’s first year meeting the expenditure threshold requiring a Single Audit, and staff were not previously aware that the Single Audit shared the same nine-month reporting requirement as the annual financial statement audit. The District is implementing procedures to prevent recurrence, including obtaining additional training on Single Audit requirements and updating internal reporting calendars to ensure timely completion in future years. The District is committed to compliance with all federal and state reporting requirements moving forward.

View Audit 384481

Finding 1170966 (2024-001)

Material Weakness 2024

County of York, Pennsylvania

PA

Student Financial Aid Reporting Internal Control / Segregation of Duties

We concur with this finding. Children, Youth and Families will explore ways to better track the State Fiscal Year and County’s Calendar Year side-by-side. The Children & Youth Fiscal team will work with the Director of Finance to implement reconciliation processes and will prioritize timeliness of r...

We concur with this finding. Children, Youth and Families will explore ways to better track the State Fiscal Year and County’s Calendar Year side-by-side. The Children & Youth Fiscal team will work with the Director of Finance to implement reconciliation processes and will prioritize timeliness of reporting.

View Audit 384337

Finding 1170944 (2024-002)

Material Weakness 2024

Gallia-Jackson-Meigs Board of Adamh

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.329

The issue has been corrected and reporting will be accurate for 2025.

View Audit 384261

Corrective Action Plans

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