Corrective Action Plans

Finding 1159853 (2024-003)

Material Weakness 2024

MN

Reporting Subrecipient Monitoring § 200.510

SHN will ensure that all Federal Awards are carefully reviewed to confirm that the Federal Assistance Listing Number is accurately stated, the pass-through entity identifying numbers are correct, and are included in the correct Cluster.

View Audit 370389

Finding 1159799 (2024-002)

Material Weakness 2024

City of Akron, Ohio

OH

Subrecipient Monitoring Material Weakness Reporting § 200.208 § 200.328

2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.

View Audit 370339

Finding 1159798 (2024-006)

Material Weakness 2024

Program of Academic Exchange

NY

Reporting

PAX has established policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed in a timely manner. The primary deliverable will be timely audit completion and submission.

View Audit 370336

Finding 1159760 (2024-001)

Material Weakness 2024

Connecticut Harm Reduction Alliance, Inc.

CT

Allowable Costs / Cost Principles Cash Management Reporting

Management will continue to request invoices from vendors in a timely manner. In the event a vendor fails to provide such invoice management will make reasonably estimate of expense to be accrued at year-end.

View Audit 370326

Finding 1159738 (2024-001)

Material Weakness 2024

Scranton Primary Health Care Center INC

PA

Reporting

SCRANTON PRIMARY HEALTH CARE CENTER INC IN THE FUTURE YEAR FILINGS OF THE DATA COLLECTION FORM AND REPORTING PACKAGE WILL OBTAIN AND COMPILE ON A TIMELY BASIS TO ALLOW THE REPORT TO BE FILED NO LATER THAN NINE MONTHS AFTER THE END OF THE AUDIT PERIOD OR EXTENDED PERIOD ALLOWED BY THE OFFICE OF MANAG...

SCRANTON PRIMARY HEALTH CARE CENTER INC IN THE FUTURE YEAR FILINGS OF THE DATA COLLECTION FORM AND REPORTING PACKAGE WILL OBTAIN AND COMPILE ON A TIMELY BASIS TO ALLOW THE REPORT TO BE FILED NO LATER THAN NINE MONTHS AFTER THE END OF THE AUDIT PERIOD OR EXTENDED PERIOD ALLOWED BY THE OFFICE OF MANAGEMENT AND BUDGET.

View Audit 370323

Finding 1159731 (2024-002)

Material Weakness 2024

Seward Association for the Advancement of Marine Science

AK

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.430

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...

To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS

View Audit 370314

Finding 1159706 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Reporting § 200.303

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...

U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25

View Audit 370288

Finding 1159698 (2024-003)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Reporting HUD Housing Programs Significant Deficiency § 200.303

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...

U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25

View Audit 370288

Finding 1159675 (2024-004)

Material Weakness 2024

Lane Council of Governments

OR

Subrecipient Monitoring Reporting § 200.331 § 200.332 § 200.510

Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monit...

Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monitoring plan for all identified subrecipients, ensuring that required monitoring activities (including review of reports and Single Audits, where applicable) are performed and documented throughout the period of performance.  Ensure the SEFA accurately reflects subrecipient relationships and amounts passed through.  This monitoring plan has already been implemented.

View Audit 370264

Finding 1159640 (2024-001)

Material Weakness 2024

Tmc Healthcare

AZ

Reporting Subrecipient Monitoring § 200.328

Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Feder...

Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Questioned Costs - N/A Context - The Federal Financial Report for the reporting period end September 29, 2024 was due December 28, 2024, however, this was not submitted until February 25, 2025. Additionally, two (2) performance reports were due during the year, however, neither were completed. The first was for the period September 30, 2023 - March 31, 2024 and was due April 30, 2024, and the second was for the period April 1, 2024 - September 30, 2024 and was due October 30, 2024. Effect - The Company did not comply with federal reporting requirements. Cause - Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Identification as a Repeat Finding - N/A Recommendation - The Company should review reporting requirements in grant award documents for all federal awards to ensure compliance. Client Planned Action: Benson Hospital agrees to the finding. The issue was identified in February of 2025 and the required reporting was completed and submitted. Going forward we have established a protocol by which reports for such Congressional Funding shall be submitted timely. Client Responsible Party: Mark Nellis, CFO; (520) 586-1873 Completion Date: February 22, 2025

View Audit 370254

Finding 1159585 (2024-002)

Material Weakness 2024

Westward Heights

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.327

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate...

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.

View Audit 370235

Finding 1159583 (2024-001)

Material Weakness 2024

Loretto Rest Realty Corporation

NY

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.

View Audit 370224

Finding 1159478 (2024-004)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159472 (2024-002)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are prop...

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159469 (2024-001)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159466 (2024-003)

Material Weakness 2024

Chaffee County

CO

Reporting § 200.303 § 200.508

Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.

View Audit 370208

Finding 1159454 (2024-004)

Material Weakness 2024

School of Excellence in Education

TX

Cash Management Reporting School Nutrition Programs

No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation ...

No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation of approval for all monthly NSLP claims for reimbursement prior to submission. We will establish a formalized procedure to ensure that all monthly claims for reimbursement undergo documented management review and approval before submission. This procedure will clearly define the review process and designate responsible personnel for each step to maintain accountability. All reviewed and approved claims will be accompanied by signed documentation as evidence of compliance. All Food Service personnel involved in the reimbursement submission process will receive training on the new procedure to ensure understanding and adherence to the documentation requirements.

View Audit 370184

Finding 1159448 (2024-003)

Material Weakness 2024

School of Excellence in Education

TX

Allowable Costs / Cost Principles Cash Management Reporting

No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage i...

No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage in the accounting system to the approved percentages in the semi-annual time and effort logs to verify accuracy. These improved internal procedures will provide proper compliance over allowable costs. Annual audit of all grant-funded employee positions at the start of each school year, reviewed by grants team, HR, and accounting to verify accuracy of all employee costing allocations to grants.

View Audit 370184

Finding 1159446 (2024-001)

Material Weakness 2024

Granby Homes for Senior Citizens, Inc.

CT

Reporting

Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Stat...

Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Statement of Concurrence or Nonconcurrence: The Project agrees with the audit finding. Corrective Action: The management certification from 3560-13 has been sent to the board president for signature on September 24, 2025, and will be submitted to USDA once received back. Name of Contact Person: Paula Tracy, President, 860-398-5425 ext. 511# paulat@wildwoodmgt.com Projected Completion Date: Management certifications have been e-mailed to the board president on September 24, 2025 and once received back will forward to USDA for final signature.

View Audit 370182

Finding 1159427 (2024-001)

Material Weakness 2024

Coastal Community Action Program

WA

Reporting Subrecipient Monitoring § 200.302

September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an...

September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an unusual reallocation of funding by the Washington State Department of Commerce. The award was originally awarded and recorded as state funds. In September 2024, the Washington State Department of Commerce reallocated a portion of its funding and amended the grant terms to designate the award as being funded under the Coronavirus State and Local Fiscal Recovery Funds (21.027). Because the reallocation and revised terms were communicated late in the fiscal year, management did not identify the change in time to ensure that the award was correctly reported as federal on the SEFA. The adjustment was therefore an oversight and not an intentional misclassification. 2024-001 Preparation of the Schedule of Expenditures of Federal Awards CCAP Executive Leadership understands the function and necessity of preparing a complete and accurate SEFA. 1. Policy and Procedures Development: By November 15, 2025, management will develop and adopt written policies and procedures requiring formal review of all grant amendments, reallocations, and correspondence from pass-through entities to determine whether funding sources have changed and whether SEFA reporting is affected. 2. Internal Control Implementation: Management will implement a dual-review process in which both the Finance Director and Grants Manager verify the funding source and assistance listing number for all awards and amendments before SEFA preparation. 3. Training: Staff responsible for grants management and financial reporting will complete training on Uniform Guidance financial management and SEFA preparation requirements by November 15, 2025, with refresher training annually thereafter. 4. Ongoing Monitoring: Management will conduct a pre-audit SEFA review each year, reconciling all awards and amendments to source documentation, including grant agreements, amendments, and communications from pass-through entities. Responsible Party: Lucy Machowek, CFO Planned Completion Date: November 15, 2025

View Audit 370154

Finding 1159425 (2024-002)

Material Weakness 2024

Capital Region Minority Supplier Development Council

MD

Reporting Significant Deficiency § 200.510

Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving lim...

Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving limited time for an adequate transfer of knowledge and responsibilities. To preserve continuity in financial operations, CRMSDC immediately engaged outsourced accounting support. Looking ahead, CRMSDC will undertake a full review of its financial management structure and secure a highly qualified accountant or financial professional with specialized expertise in nonprofit accounting and federal grant compliance. Combined with strengthened procedures and enhanced supervisory oversight, these actions will build organizational capacity, reinforce internal controls, and ensure accurate and timely financial reporting. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: Assessment and Correction – 4th Quarter 2025

View Audit 370152

Finding 1159417 (2024-004)

Material Weakness 2024

Supports to Encourage Low Income Families INC

OH

Reporting Internal Control / Segregation of Duties

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...

In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.

View Audit 370141

Finding 1159414 (2024-002)

Material Weakness 2024

Heart of Ohio Family Health Centers

OH

Reporting

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...

Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Angelita Thomas, Chief Financial Officer

View Audit 370139

Finding 1159411 (2024-001)

Material Weakness 2024

Center for Asbestos Related Disease

MT

Reporting § 200.516

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm...

Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing

View Audit 370138

Finding 1159410 (2024-001)

Material Weakness 2024

Grady Memorial Hospital Corporation

GA

Allowable Costs / Cost Principles Cash Management Reporting § 200.303

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...

To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting

View Audit 370132

Corrective Action Plans

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