Corrective Action Plans

Finding 1170506 (2023-006)

Material Weakness 2023

OH

Internal Control / Segregation of Duties Questioned Costs Reporting § 200.303

SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.

View Audit 383712

Finding 1170476 (2023-003)

Material Weakness 2023

Bedford Stuyvesant Restoration Corporation and Affiliates

NY

Questioned Costs Reporting Equipment & Real Property Management

Single Audit Reporting for June 30, 2023 Finding: The Restoration did not follow the process in place for ensuring that the Single Audit reporting requirements were satisfied on a timely manner. The audit of the Restoration’s basic financial statements was not completed prior to the Single Audit rep...

Single Audit Reporting for June 30, 2023 Finding: The Restoration did not follow the process in place for ensuring that the Single Audit reporting requirements were satisfied on a timely manner. The audit of the Restoration’s basic financial statements was not completed prior to the Single Audit reporting deadlines. Contact Person: Leah M. Sparrow, WAP Director Marrolin Beauzile, Accountant Corrective Actions Taken or Planned: Restoration has implemented changes in staff that will lead the audit and lead the reporting of the program activities and program management. We are determined to complete the next two audit years (FY24 and FY25) expeditiously. We believe that these changes will lead to positive results within the next year. Anticipated completion date: December 31, 2026

View Audit 383646

Finding 1170475 (2023-002)

Material Weakness 2023

Bedford Stuyvesant Restoration Corporation and Affiliates

NY

Questioned Costs HUD Housing Programs Reporting

Reporting Finding: We noted that for the year ended June 30, 2023, monthly reports for Weatherization Assistance Program (WAP) ending 12/31/22, 01/31/23 and 04/30/23 which are due on the 20th day of the following month were submitted on 01/24/23, 02/21/23 and 05/22/23, respectively and the final CFR...

Reporting Finding: We noted that for the year ended June 30, 2023, monthly reports for Weatherization Assistance Program (WAP) ending 12/31/22, 01/31/23 and 04/30/23 which are due on the 20th day of the following month were submitted on 01/24/23, 02/21/23 and 05/22/23, respectively and the final CFR dated 06/30/23 was submitted on 09/25/23. While for American Rescue Plan Act (ARPA), monthly report ending 01/31/23 which is due on the 20th day of the following month was submitted on 02/21/23. Contact Person: Leah M. Sparrow, WAP Director Marrolin Beauzile, Accountant Corrective Actions Taken or Planned: In the later part of 2025 the agency has placed a new Program Director to oversee the program in 2025. Therefore, it was only until then that major changes began to show in our records. We plan to review the process of submitting monthly reports. We will conduct meetings with the staff responsible for submission to understand the reason for late submissions. Anticipated Completion Date: March 31, 2026.

View Audit 383646

Finding 1170351 (2023-001)

Material Weakness 2023

New Directions, Inc.

CA

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.

View Audit 383444

Finding 1169874 (2023-003)

Material Weakness 2023

City of Reedsburg

WI

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

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do n...

Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor

View Audit 383031

Finding 1169574 (2023-004)

Material Weakness 2023

First Choice Community Healthcare, Inc.

NM

Reporting § 200.512

2023-004 – Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are ...

2023-004 – Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2026

View Audit 382567

Finding 1169431 (2023-002)

Material Weakness 2023

Comanche County Medical Center

TX

Questioned Costs Cash Management Reporting

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses ...

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

View Audit 382372

Finding 1169158 (2023-002)

Material Weakness 2023

City of Tahlequah

OK

Reporting Internal Control / Segregation of Duties

Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s...

Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding SEFA preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.

View Audit 382015

Finding 1169157 (2023-003)

Material Weakness 2023

City of Tahlequah

OK

Reporting Internal Control / Segregation of Duties

Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report ...

Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report to the FAC within nine months from year ending June 30, 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines in order to remain compliant with the requirements. Management has made Professional Services changes to ensure timely audit compliance moving forward.

View Audit 382015

Finding 1169156 (2023-004)

Material Weakness 2023

City of Tahlequah

OK

Reporting

Finding 2023-004 – Reporting Compliance Requirements of Federal Funds Condition: The City’s internal controls over reporting compliance requirements were not thoroughly monitored and were not timely, and reports were not accurately submitted. In conjunction with our FY2023 single audit, please see t...

Finding 2023-004 – Reporting Compliance Requirements of Federal Funds Condition: The City’s internal controls over reporting compliance requirements were not thoroughly monitored and were not timely, and reports were not accurately submitted. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding report preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.

View Audit 382015

Finding 1168942 (2023-002)

Material Weakness 2023

Town of Malden

WA

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The Town did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of Town contact person: Dan Harwood, Mayor PO Box 248, Malden, Washington 99149 (509) 569-3771 Corrective action the auditee plans to take in response to the finding: We agree with the SAO staff as far as the Town staff being new to federal grants and the requirements of recordkeeping associated with it. It is obvious that the Town staff can not handle the workload of administering all the grants that the town has obtained since the 2020 Babb Road Fire. We are in the process of contracting an outside party that will handle most of the current grants. The Town staff thought they processed all the certified payroll information that was received. We were surprised that there were some missing. The State Department of Commerce has been working with the staff on making sure that the certified payroll process was complete. With any future grants we will make sure that Town staff will pursue training on Certified Payroll to make sure all papers are received. Anticipated date to complete the corrective action: These actions will be done when we receive future federal grants.

View Audit 381466

Finding 1168849 (2023-004)

Material Weakness 2023

City of Upper Sandusky

OH

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.302 § 200.328 § 200.329

The City will work to ensure all reports for grant funding are completed.

View Audit 381205

Finding 1168848 (2023-003)

Material Weakness 2023

City of Upper Sandusky

OH

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.329

The City will work to ensure all reports for grant funding are completed.

View Audit 381205

Finding 1168737 (2023-003)

Material Weakness 2023

Morton-Sioux Special Education Unit

ND

Allowable Costs / Cost Principles Reporting § 200.512

2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June ...

2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June 30, 2025 audit.

View Audit 380801

Finding 1168604 (2023-002)

Material Weakness 2023

Line Mountain School District

PA

Subrecipient Monitoring Reporting

Finding 2023-2 –Reporting Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over grant reporting to ensure all required Reconciliation of Cash on Hand Quarterly Reports and final expenditure reports are prepared accurate...

Finding 2023-2 –Reporting Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over grant reporting to ensure all required Reconciliation of Cash on Hand Quarterly Reports and final expenditure reports are prepared accurately and submitted timely in accordance with grant requirements. The District should implement a formal review and monitoring process and provide training to staff responsible for grant reporting to ensure ongoing compliance. Action: The District Office will work directly with the Federal Programs Coordinator to ensure more timely submissions of Reconciliation of Cash on Hand Quarterly Reports and Final Expenditure Reports are prepared accurately and submitted timely in accordance with grant requirements. The Business Manager will do this by creating reminders on the Business Manager’s calendar that include due dates each quarter and reminding the Federal Programs Coordinator when their respective reports are due. The District will implement and form a review and monitoring process and provide any necessary training to staff responsible for grant reporting to ensure ongoing compliance. Date for Completion: These steps have already been put into place and will continue to be built upon.

View Audit 380500

Finding 1168598 (2023-005)

Material Weakness 2023

City of Lock Haven, Pennsylvania

PA

Questioned Costs Subrecipient Monitoring Reporting

The City has engaged an independent accountant and works with its financial advisors to ensure future audits are completed in a timely manner.

View Audit 380490

Finding 1168443 (2023-001)

Material Weakness 2023

Cheyenne-Eagle Butte Airport Association, Inc.

SD

Questioned Costs Reporting

Finding 2023-001: Uniform Guidance Audit Requirement Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will work to complete future audits timely. Anticipated Completion Date: Future federal programs.

View Audit 380219

Finding 1168081 (2023-005)

Material Weakness 2023

NEW YORK CITY FOUNDATION FOR COMPUTER SCIENCE EDUCATION, INC.

NY

Reporting Matching / Level of Effort / Earmarking Questioned Costs § 200.301 § 200.328 § 200.512

Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key docu...

Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key documents were often stored under individual employee drives rather than within a shared, organization-controlled system. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization had limited capacity to implement formal reporting controls; however, foundational corrective steps were initiated in 2025 to support full compliance during the 2026 operating year. Corrective Action taken in 2025: The Operations Manager conducted a full triage of existing accounts and transferred organizational documents into centralized CSforALL Drives. Files were reorganized by year and subject matter to ensure accessibility, consistency, and proper retention. This restructured system now provides a unified location for all grant-related documents, reporting records, and compliance materials, establishing a baseline for future Uniform Guidance reporting requirements. Corrective Action Planned for 2026: Beginning in 2026, CSforALL will implement formalized policies and procedures to ensure records are maintained in accordance with applicable compliance requirements and that all Uniform Guidance reports are submitted timely. The Operations Manager and Accounting team will oversee ongoing documentation, retention, and periodic internal review to ensure the reporting structure remains organized, accessible, and compliant throughout the 2026 operating year and beyond. Page

View Audit 379802

Finding 1168060 (2023-003)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.303

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.

View Audit 379692

Finding 1167998 (2023-001)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024

View Audit 379692

Finding 1167985 (2023-004)

Material Weakness 2023

Lone Pine Paiute- Shoshone Reservation

CA

Questioned Costs Eligibility Material Weakness § 200.329

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the award...

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the awarding agency as required. Corrective Action: The Tribe has hired a full-time bookkeeper along with a new fiscal consultant to assist the bookkeeper in journal entries, bank statements, etc. on a monthly basis. All required reporting will be done within 30 days of the end of reporting date. Anticipated date of completion: April 1, 2026.

View Audit 379637

Finding 1167934 (2023-006)

Material Weakness 2023

County of Carbon

PA

Reporting Subrecipient Monitoring

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available; 21.027, COVI D-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: The tracking and matching of grant revenues and expenditures and the related grant receivable and unearned revenue amounts is necessary to assist in making management decisions and for the proper reporting and use of those funds in accordance with each of the individual grant requirements. In addition, this information is essential in preparing the County's Schedule of Expenditures of Federal Awards (SEFA}. Condition/Context: The County's system of tracking its grants and matching revenues with expenditures lacks the necessary level of sophistication, given the number and complexities of the County's grant activities, which hampers the County's ability to maintain an accurate general ledger and prepare a complete and accurate SEFA. The current year SEFA also required the restatement of beginning accrued revenue balances. Effect: Grants receivable and unearned revenue amounts are not readily ascertainable to assist in making management decisions or for use in the timely preparation of the County's SEFA. The County did not prepare a complete and accurate SEFA in a timely manner to comply with its financial reporting requirements. Cause: The County has not prioritized a formal system for tracking its grant activities. Recommendation: We recommend that the County develop and implement a formal system for tracking its grant related activities and in doing so require that all departments with responsibility for federal award programs provide periodic reconciliations of their grant reports to the general ledger to a responsible management official. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the restatement of the beginning accrued revenue balances on the SEFA and is working to realign staff responsibilities to provide a dedicated business office staff member to oversee, track, report and manage all of the County's grant awards. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026

View Audit 379448

Finding 1167925 (2023-005)

Material Weakness 2023

County of Carbon

PA

Questioned Costs Student Financial Aid Subrecipient Monitoring

Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity...

Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2022 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2022 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the County hopes to have cleared by the 2025 audit. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026

View Audit 379448

Finding 1167814 (2023-003)

Material Weakness 2023

Pohnpei Utilities Corporation

FM

Special Tests & Provisions HUD Housing Programs Reporting

PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO

View Audit 379154

Finding 1167725 (2023-010)

Material Weakness 2023

Defensewerx

FL

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.302 § 200.328

We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be ...

We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be easily reconciled to the underlying accounting records.

View Audit 378959

Corrective Action Plans

Filters