Corrective Action Plans

Finding 1205797 (2024-017)

Material Weakness 2024

City of Mission

TX

Cash Management Reporting Significant Deficiency

The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director / Vidal Roman, Finance Director ...

The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director / Vidal Roman, Finance Director Timeline to Complete: Estimated June 2026

View Audit 397522

Finding 1205793 (2024-018)

Material Weakness 2024

City of Mission

TX

Eligibility Reporting Significant Deficiency

The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into formal grant management policy. Responsible Officials: Michael Elizalde, Grants &...

The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into formal grant management policy. Responsible Officials: Michael Elizalde, Grants & Strategic Initiatives Director Timeline to Complete: Estimated June 2026.

View Audit 397522

Finding 1205774 (2024-003)

Material Weakness 2024

City of Chickasha, Oklahoma

OK

Procurement, Suspension & Debarment Eligibility Reporting § 200.512

Views of Responsive Officials of Auditee: Management recognizes that the City’s audits have not been completed within the required statutory deadlines in recent years, including the reporting delay noted in this finding. These delays were primarily the result of turnover and transition in key financ...

Views of Responsive Officials of Auditee: Management recognizes that the City’s audits have not been completed within the required statutory deadlines in recent years, including the reporting delay noted in this finding. These delays were primarily the result of turnover and transition in key financial staff positions, which impacted continuity and the timely completion of audit-related activities. At the same time, management would like to highlight the significant progress that has been made in addressing this issue. Over the past six months, the City has successfully completed two fiscal year audits, representing meaningful advancement toward eliminating the audit backlog. Management is committed to continuing this progress and has established a plan to return to full compliance with reporting deadlines. The City anticipates being fully current beginning with the FY-2027 audit cycle and will continue implementing process improvements and ensuring staffing stability to support timely audit completion. Management understands the importance of timely reporting, particularly as it relates to maintaining eligibility for federal funding and will prioritize adherence to all applicable deadlines moving forward.

View Audit 397519

Finding 1205772 (2024-004)

Material Weakness 2024

Midwest Organic Association Inc

WI

Reporting

Agency: U.S. Department of Agriculture Responsible Person, Title: Cori Skolaski, ED Completion date: 2026 Agency Response: Concur Corrective Action Plan: The Association will file reports timely for the year ended December 31, 2025 and any future years.

View Audit 397509

Finding 1205763 (2024-002)

Material Weakness 2024

Missoula County

MT

Reporting

Corrective Action Plan In the audit schedule of findings for the year ended June 30, 2024, the auditors identified the following item in the financial statements. The County’s corrective action plan for this item is addressed below. Finding 2024-001 – Internal Control Over Financial Reporting and Ac...

Corrective Action Plan In the audit schedule of findings for the year ended June 30, 2024, the auditors identified the following item in the financial statements. The County’s corrective action plan for this item is addressed below. Finding 2024-001 – Internal Control Over Financial Reporting and Account Adjustments including the Schedule of Expenditures of Federal Awards Missoula County will begin with FY25 year-end financial reporting to provide additional training to all staff related to Financial Statement reporting. Due to staffing issues, an accounting firm will continue to support Missoula County staff in meeting deadlines with accurate information. A thorough review of all practices, policies and procedures will continue over the next fiscal year to ensure key control activities are in place. Each staff person involved with Financial Reporting will be trained on the key control activities and their importance. This information has been used in implementing a new Financial Software application which allows for business process workflows to aid departments in completing financial transactions accurately. The business process workflows include appropriate internal controls and review steps to ensure accuracy of entries. In addition, a new process for tracking monthly, quarterly and year end adjustments will be implemented. This process includes a second individual to review the year end reports for completeness, adherence to GAAP and monitoring of information reported on the Schedule of Expenditures of Federal Awards. Contact Person Responsible for Corrective Action: Michelle Denman, Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2026 Finding 2024-002 – U.S. Department of Treasury COVID 19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF)-ALN 21.027 Reporting Missoula County has implemented a dual control process over CSLFRF reporting. Prior to quarterly reporting, the accountant in finance will review all expenditures related to obligated ARPA programs and reconcile this activity with each department expenditures. At the end of the quarter, after all months have closed and prior to Treasury reporting, an additional review of prior quarter activity will occur to ensure any reclassification journals have been noted to ensure prior quarter reports can be updated. Contact Person Responsible for Corrective Action: Michelle Denman, Financial Services Director Anticipated Completion Date of the Corrective Action: June 30, 2026

View Audit 397500

Finding 1205742 (2024-005)

Material Weakness 2024

Excelsior Springs Hospital

MO

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.

View Audit 397466

Finding 1205735 (2024-001)

Material Weakness 2024

County of Coos, New Hampshire

NH

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303

The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expendit...

The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expenditures and revenues per grant on amounts reported within the general ledger and amounts included on subsidiary tracking spreadsheets. This verification (crosswalk) should include specific general ledger account numbers used for tracking revenues and expenditures. 2. Supervisory Review: Reconciliations should be reviewed and signed off by a person independent of the spreadsheet preparation 3. System Integration: In January 2025, the County implemented a new ERP software system, which offers a grant module and features to identify grant items to help eliminate reliance on manual “shadow” systems or spreadsheets.

View Audit 397440

Finding 1205409 (2024-005)

Material Weakness 2024

City of Dunkirk Housing Authority

NY

HUD Housing Programs Reporting

2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Managem...

2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its submissions were not timely. Management engaged the services of a fee-accountant subsequent to year-end who will assist with these submission going forward. In order to submit and ensure integrity of the unaudited financial statements, the bank accounts reconciliations needed to be completed and account analysis performed. Management will continue to prioritize and remediate outstanding compliance obligations and develop a compliance catch-up plan to ensure timely account reconciliation and account analysis in the future. The fee accountant was not re-engaged to perform bank reconciliations and account analysis for the year ended June 30, 2025 until after June 30, 2025 year end. As a result, management expects this to be a repeat finding in the June 30, 2025 audit.

View Audit 397084

Finding 1205398 (2024-004)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Reporting § 200.303 § 200.502 § 200.510

Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and i...

Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and internal controls to ensure accurate reporting of the Schedule as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA department created a standard pre-award approval process for all sponsored proposals prior to submission or award acceptance. The pre-award approval process applies to all federal, state, local, private and commercial funding opportunities across all UMMS entities and covers new, renewal, resubmission and supplemental proposals. The establishment of a central intake process through one department, for all grants across the Corporation, enhances the controls to ensure complete and accurate reporting of the Schedule as required by the Uniform Guidance. Additionally, ORSPA and Corporate Financial Reporting implemented the following controls to ensure all expenditures of federal awards are included on the Schedule. These controls include:  Reconciliation of the grants from the pre-award approval process to the grants tagged in the accounting system;  Use of a specific grant identifier within the accounting system to track expenditures and revenue recognition and tag grants as federal, state or private funded;  Comparison of grant expenditures per the accounting system to the grant agreement;  Comparison of grant expenditures per the accounting system to the financial reporting submissions made to the federal agencies;  Certification from legal entity Finance Executives that the draft Schedule is complete and accurate;  Comparison of the prior year Schedule to the current year Schedule with further investigation around changes in grants and agencies included, and significant changes in the expenditures. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205395 (2024-002)

Material Weakness 2024

University of Maryland Medical System Corporation

MD

Allowable Costs / Cost Principles Cash Management Reporting

C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: M...

C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management is developing standard operating procedures and policies that include the requirements for compliance and internal controls for federal grants. The policies will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

View Audit 397083

Finding 1205245 (2024-005)

Material Weakness 2024

Save the Michael's of the World

NY

Reporting

The Organization has engaged an audit firm to complete the 2024 audit and is implementing procedures to ensure the Single Audit is completed and submitted in a timely manner in future years.

View Audit 396940

Finding 1205186 (2024-003)

Material Weakness 2024

Morgan County

OH

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.202 § 200.208 § 200.301 § 200.328

The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accor...

The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accordance with those requirements.

View Audit 396842

Finding 1205047 (2024-001)

Material Weakness 2024

Detroit Police Athletic League, Inc.

MI

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

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.

View Audit 396692

Finding 1205009 (2024-004)

Material Weakness 2024

Innovative Health Solutions

CA

Reporting Cash Management Program Income

Finding 2024-04 Schedule of Expenditures of Federal Awards. Management concurs with the finding. IHS will be working with the new outside CPA firm to develop a grant bridging report beginning FY2025/26.

View Audit 396668

Finding 1205006 (2024-001)

Material Weakness 2024

Innovative Health Solutions

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.

View Audit 396668

Finding 1205003 (2024-006)

Material Weakness 2024

The City of Frederick, Maryland

MD

Subrecipient Monitoring Reporting Material Weakness

Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In ad...

Finding reference: 2024-006 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Reporting - FFATA Recommendation: We recommend the City establish and implement controls to maintain compliance with reporting requirements. Action taken: In addition to hiring a grant manager to oversee compliance, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant. This system is designed to send notifications of reporting requirements prior to the due date.

View Audit 396662

Finding 1205002 (2024-005)

Material Weakness 2024

The City of Frederick, Maryland

MD

Reporting

Finding reference: 2024-005- 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with correspondi...

Finding reference: 2024-005- 93.137 – Community Programs to Improve Minority Health Grant Program Significant Deficiency and Noncompliance over Reporting – Financial Report Recommendation: Program management and the Finance Department should maintain a schedule of required reporting with corresponding due dates. A designated employee should be assigned to monitor the report submissions with the goal that reports should be submitted timely, in compliance with the grant agreements. Action taken: In addition to hiring a grant manager, the City has purchased OpenGov grant software to ensure compliance, monitoring and the insurance of timely submissions in accordance with the grant

View Audit 396662

Finding 1204879 (2024-002)

Material Weakness 2024

Village of Glenmont

OH

Matching / Level of Effort / Earmarking Subrecipient Monitoring Period of Performance § 200.329

The Fiscal Officer will improve tracking and reporting procedures by requesting a clear outline from all funding and liaising parties at the start of all future projects. As well as making sure all reporting and procedures are adhered to by those parties.

View Audit 396497

Finding 1203104 (2024-001)

Material Weakness 2024

Town of Oak Bluffs

MA

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

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C....

CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Financial Statement Finding 2024-001 – Document Policies and Procedures Over Federal Awards Condition: During our audit, we noted that the Town did not have formal policies and procedures in place covering the requirements of Uniform Guidance as specified in 2 CFR Part 200. Certain elements, such as procurement standards, subrecipient monitoring, internal control, and other compliance areas, were not addressed in written policies or documented procedures. Criteria: Uniform Guidance (2 CFR Part 200) requires non-federal entities administering federal awards to establish and maintain written policies and procedures to address all requirements specified in the regulations, including but not limited to internal controls, determination of allowable costs, procurement, subrecipient monitoring, financial management, and reporting. Cause: The Town has not developed comprehensive written policies and procedures to address all compliance requirements under Uniform Guidance. Effect: The absence of written policies and procedures increases the risk of noncompliance with federal requirements, reduces consistency in federal program administration, and limits transparency and accountability. Recommendation The Town should develop and implement comprehensive written policies and procedures that address all major compliance requirements under Uniform Guidance (2 CFR Part 200). Periodic review and updates should be performed to ensure ongoing compliance. Views of Responsible Officials: We have been reviewing existing workflows, and unwritten procedures, relative to our management and oversight of federal awards either received directly from the federal or from another intermediary pass-through agency. Once our review is complete, we will commit those procedures to writing and present them to the Select Boad for approval. The anticipation is that we will have documented policies and procedures, that are compliant with the Uniform Guidance, in time for the FY2026 audit.

View Audit 396313

Finding 1201382 (2024-001)

Material Weakness 2024

Salina Airport Authority

KS

Reporting

2024-001 – 20.106 – Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs – Reporting Condition Two of the six reports tested had an inaccurate amount or amounts included on the reporting. Recommendation We recommend that the Authority review it...

2024-001 – 20.106 – Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs – Reporting Condition Two of the six reports tested had an inaccurate amount or amounts included on the reporting. Recommendation We recommend that the Authority review its internal controls to ensure that all reporting submitted is completed accurately. Comments on the Finding We agree with the finding. Action Taken Will include a manager review of each federal report submitted. In addition to the manager and/or staff member preparing the report.

View Audit 395960

Finding 1191626 (2024-001)

Material Weakness 2024

Hawkeye Properties and Workforce Innovation, Inc.

CA

Reporting Internal Control / Segregation of Duties § 200.510 § 200.512

Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Feder...

Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Federal Awards for the fiscal year ended June 30, 2025.

View Audit 395484

Finding 1191602 (2024-003)

Material Weakness 2024

First Nations Community Healthsource, Inc.

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action FNCH recognizes the critical importance of establishing robust interna...

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages. Management Response Corrective Action FNCH recognizes the critical importance of establishing robust internal controls to guarantee the timely preparation and accurate submission of reports and records for audit purposes, particularly in alignment with the requirements outlined in 2 CFR 200.512. To effectively implement these internal controls, management will enforce procedures for the timely preparation of all necessary reports and records, including the Schedule of Expenditures of Federal Awards (SEFA). This will not only facilitate smoother audit processes but also ensure adherence to the 2 CFR 200.512. Management will train staff and establish timelines and responsibilities for report preparation and documentation to enhance compliance and streamline overall operations. Expected Outcome: • On‑time Single Audit filings in compliance with federal rules. • Clear visibility and accountability for deadlines. • Reduced risk of penalties and funding delays. • Greater confidence from agencies and stakeholders. Due Date of Completion: 3 days following issuance of the audit report Responsible Party(ies): CEO, CFO

View Audit 395458

Finding 1191571 (2024-001)

Material Weakness 2024

Hogar Fortaleza Del Caido, Inc.

PR

Reporting § 200.512

Full text of the Corrective Action Plan includes a chart, table or footnotes.

View Audit 395441

Finding 1191112 (2024-001)

Material Weakness 2024

Keams Canyon Elementary School

AZ

Reporting Internal Control / Segregation of Duties

The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.

View Audit 395263

Finding 1190888 (2024-001)

Material Weakness 2024

The Ward Burton Wildlife Foundation

VA

Reporting

The Ward Burton Wildlife Foundation will implement an enhanced internal process to ensure timely completion and submission of all future audit requirements. This corrective action focuses on improving the management and monitoring of Suralink assignments. Going forward Jacob will be the primary cont...

The Ward Burton Wildlife Foundation will implement an enhanced internal process to ensure timely completion and submission of all future audit requirements. This corrective action focuses on improving the management and monitoring of Suralink assignments. Going forward Jacob will be the primary contact and receive notifications whenever a new Suralink task is assigned to ensure visibility and shared accountability. Additionally, a tracking protocol will be implemented whereby any assigned task not completed by Jacob within two weeks of assignment will trigger follow-up review and reassignment or escalation as necessary. This internal control is intended to prevent delays in document submission and ensure consistent progress throughout the audit process. These improvements are designed to ensure that all required documentation is completed and submitted in a timely manner, allowing the Foundation to meet all audit deadlines and complete future audits within the required nine-month reporting window.

View Audit 395186

Corrective Action Plans

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