Corrective Action Plans

Finding 1159903 (2022-004)

Material Weakness 2022

Access for Community & Cultural Education Programs & Trainings

NV

Cash Management Reporting Significant Deficiency

Planned Corrective Action: ACCEPT was approved by the Nevada Department of Public and Behavioral Health to submit RFRs as soon as possible in FY22. ACCEPT has followed this approval and submitted all requests by the 15th day of the month following the aforementioned month. Name of Contact Person: Gw...

Planned Corrective Action: ACCEPT was approved by the Nevada Department of Public and Behavioral Health to submit RFRs as soon as possible in FY22. ACCEPT has followed this approval and submitted all requests by the 15th day of the month following the aforementioned month. Name of Contact Person: Gwen Taylor, Executive Director

View Audit 370443

Finding 1159823 (2022-007)

Material Weakness 2022

Republic of Palau

PW

Reporting Subrecipient Monitoring Significant Deficiency § 200.303

We concur with the finding. The ETA 9130 reports for FY22 were based on estimates due to limitations in the reliability of the WIOA accounting system at that time.

View Audit 370385

Finding 1155424 (2022-011)

Material Weakness 2022

Headquarters Kansas, Inc.

KS

Significant Deficiency Internal Control / Segregation of Duties § 200.303

2022-011 Written Controls over Compliance (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management has worked to update its control procedures to ...

2022-011 Written Controls over Compliance (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management has worked to update its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. To address this, the organization hired an outside accounting firm as a consultant in January 2024 and updated its policies, the most recent update in February 2025 with review continuing as audits for 2023 and 2024 .

View Audit 367706

Finding 1155423 (2022-010)

Material Weakness 2022

Headquarters Kansas, Inc.

KS

Significant Deficiency Internal Control / Segregation of Duties § 200.512

2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures t...

2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies related to audits was completed November 2024. The organization will complete an additional review of the policies compared to Uniform Guidance 1st Quarter 2026.

View Audit 367706

Finding 1155016 (2022-009)

Material Weakness 2022

Ulster County Community Action Committee, Inc.

NY

Reporting Significant Deficiency § 200.508 § 200.510

UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness...

UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness. Responsible Person: Controller and program directors Timeline: 30-60 days

View Audit 367339

Finding 1153884 (2022-001)

Material Weakness 2022

Monterey County Business Council

CA

Cash Management Reporting Significant Deficiency

Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over rep...

Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2022. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2022 audit by August 30, 2025. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111

View Audit 366960

Finding 575857 (2022-004)

Significant Deficiency 2022

Abilities Network, Inc.

MD

Period of Performance Allowable Costs / Cost Principles Significant Deficiency § 200.1

Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. E...

Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2025

View Audit 365817

Finding 574852 (2022-003)

Significant Deficiency 2022

Whitman-Hanson Regional School District

MA

Period of Performance Allowable Costs / Cost Principles Reporting § 200.309

WHRSD has recently redesigned its Chart of Accounts and deployed a current ERP software program to assist in controls of expenditures of all accounts including grants. WHRSD will be completing a comprehensive review of all Business Office Procedures in the fall of 2025, and plans to update/implement...

WHRSD has recently redesigned its Chart of Accounts and deployed a current ERP software program to assist in controls of expenditures of all accounts including grants. WHRSD will be completing a comprehensive review of all Business Office Procedures in the fall of 2025, and plans to update/implement updated standard operating procedures to ensure compliance with Local, State, and Federal laws.

View Audit 365120

Finding 574765 (2022-002)

Significant Deficiency 2022

The County of Lebanon, Pennsylvania

PA

Internal Control / Segregation of Duties Material Weakness Reporting

Anticipated Contact Finding: 2022-002 Agency: Lebanon County Commission on D&A Abuse Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title: Segregation of Duties over Reporting Corrective Action: The Department was in need of additional accounting...

Anticipated Contact Finding: 2022-002 Agency: Lebanon County Commission on D&A Abuse Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title: Segregation of Duties over Reporting Corrective Action: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward. Completion Date: December 2023

View Audit 365063

Finding 574044 (2022-003)

Significant Deficiency 2022

County of Rockingham

NH

Reporting Significant Deficiency § 200.303

Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission p...

Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission portal, etc.). These confirmations will be retained in a designated compliance folder for each program. 2. Contingency Plan for System Errors: The County will develop a written contingency plan to address delays caused by system outages or data access issues. This plan will include communication protocols with software vendors, documentation of incidents, and immediate outreach to the granting agency when delays are anticipated. 3. Documenting Extensions and Agency Communication: In any case where a reporting deadline cannot be met, staff will immediately request written approval for extensions from the granting agency, and this correspondence will be retained as part of the official reporting record, as applicable and permitted. 4. Training for Program and Compliance Staff: Staff involved in federal reporting will receive training on reporting deadlines, documentation standards, and escalation protocols for delays. This training will be updated annually to reflect current guidance and program requirements. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 364627

Finding 574040 (2022-001)

Significant Deficiency 2022

County of Rockingham

NH

Reporting Significant Deficiency

Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required...

Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required to be reported under Federal Assistance Listing Number (ALN) 93.498- COVID-19 - Provider Relief Fund. This resulted in an incomplete reporting of federal expenditures under the appropriate ALN. To address this issue, the County will implement the following corrective actions: 1. Training and Guidance: Staff responsible for SEF A preparation will receive additional training regarding federal reporting requirements, including how to align HRSA filings with SEFA reporting and the appropriate identification of Assistance Listing Numbers. 2. Improved Coordination: The County will establish closer coordination between the departments submitting reports to federal agencies (such as HRSA) and those compiling the SEFA to ensure consistency and completeness. 3. Periodic Reconciliations: The County will implement periodic reconciliations of its general ledger and departmental grant records against federal reporting requirements throughout the fiscal year, rather than waiting until year-end. This will support more timely and accurate SEFA preparation. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 364627

Finding 573814 (2022-005)

Significant Deficiency 2022

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Significant Deficiency

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submi...

1. Improvement of Data Entry and Documentation Management: *The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. *Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: *A regular internal review and audit process will be revisited to ensure that backup, storage, and retention practices are being followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. *Any discrepancies or issues identified during audits will be addressed promptly, and corrective actions will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: *Training sessions will be conducted for all relevant staff on the updated backup, storage, and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. *Refresher training will be provided quarterly to ensure ongoing compliance and awareness.

View Audit 364481

Finding 573379 (2022-003)

Significant Deficiency 2022

Kama'aina Care, Inc.

HI

Subrecipient Monitoring Reporting Significant Deficiency

Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.

View Audit 364154

Finding 573220 (2022-002)

Significant Deficiency 2022

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

Internal Control / Segregation of Duties Reporting Significant Deficiency

Managements Corrective Action Plan Year Ending – December 31, 2022 Schedule of finding and Questioned Costs: Section II – Financial Statement Findings: 2022-001 – Internal Control over Patient Accounts Receivable Financial Close and Reporting Section III – Federal Award Findings: 2022-002 - Reportin...

Managements Corrective Action Plan Year Ending – December 31, 2022 Schedule of finding and Questioned Costs: Section II – Financial Statement Findings: 2022-001 – Internal Control over Patient Accounts Receivable Financial Close and Reporting Section III – Federal Award Findings: 2022-002 - Reporting ALN #93.217 Contact: Jennifer Moore Title: Controller Completion Date – September 2024 Corrective Action – Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings:  We have redefined the allowance calculation methodology, relying on historical analysis and improved reporting that more accurately determines the doubtful receivables.  In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process.

View Audit 364043

Finding 571394 (2022-004)

Significant Deficiency 2022

Lake Health District

OR

Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303

Management is aware of deposit requirements and has committed the resources to ensure minimum deposit requirements are met.

View Audit 362331

Finding 571393 (2022-003)

Significant Deficiency 2022

Lake Health District

OR

Matching / Level of Effort / Earmarking Reporting Significant Deficiency § 200.512

Management is aware of reporting requirements and has committed the resources to ensure timely filing for future reports.

View Audit 362331

Finding 571312 (2022-001)

Significant Deficiency 2022

North Central Alabama Regional Council of Local Governments

AL

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

FINDINGS- FINANCIAL STATEMENT AUDIT SIGNFICANT DEFICIENCY Finding 2022-001 - Reporting : The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Audit Finding 2022-001 : Background: In March of 2022...

FINDINGS- FINANCIAL STATEMENT AUDIT SIGNFICANT DEFICIENCY Finding 2022-001 - Reporting : The U.S. Economic Development Administration ALN # 11 .307 require reports to the appropriate federal agency for revolving loan funds and grants. Response to Audit Finding 2022-001 : Background: In March of 2022 , NARCOG had a transition of leadership in the Finance Department. The new Finance Director had to be set up as an authorized representative for the organization before reporting could be submitted, which caused a delay in reporting in a timely manner. The Finance Director is still learning the process and requirements of the financial data for the reporting. Conclusion: Going forward NARCOG will have a three-member team to ensure that reporting is submitted in a timely manner. The Finance Director, Executive Director, and Planning Director will all have the capability of completing and submitting reports.

View Audit 362261

Finding 570879 (2022-004)

Significant Deficiency 2022

Homeless Resource Council of the Sierras

CA

Subrecipient Monitoring Significant Deficiency

We agree with this finding and will document approval for changes in budgets with subgrantees.

View Audit 361819

Finding 570876 (2022-001)

Significant Deficiency 2022

Homeless Resource Council of the Sierras

CA

Reporting Significant Deficiency § 200.512

We agree with this finding and are in the process of preparing for and completing the June 30, 2023 and June 30, 2024 audits. We plan to have the June 30, 2024 single audit filed by the deadline date.

View Audit 361819

Finding 570778 (2022-007)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721

Finding 570739 (2022-003)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Questioned Costs Allowable Costs / Cost Principles Material Weakness § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721 Questioned Costs: $1

Finding 570734 (2022-002)

Material Weakness 2022

Joint Programs of the Shoshone and Arapaho Tribes of the Wind River Reservation

WY

Cash Management Material Weakness Reporting § 200.303

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

View Audit 361721

Finding 570503 (2022-003)

Significant Deficiency 2022

City of Princeton

IN

Subrecipient Monitoring Reporting Significant Deficiency § 200.302 § 200.328

FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting ...

FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Significant Deficiency Condition: The City did not have proper controls in place to ensure that the annual report was accurately filled out and agreed to underlying detail. Context: Variances to key line items were noted when comparing the Form RD442-2 and Form RD442-3 to supporting documents. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that reports agree to underlying detail. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

View Audit 361490

Finding 570502 (2022-002)

Significant Deficiency 2022

City of Princeton

IN

Equipment & Real Property Management Procurement, Suspension & Debarment Significant Deficiency § 200.303 § 200.313

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compli...

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compliance Requirements: Equipment and Real Property Management Audit Findings: Significant Deficiency Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The City did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the capital asset listing is maintained throughout the year and CIP is tracked. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

View Audit 361490

Finding 570479 (2022-001)

Significant Deficiency 2022

Clean Fuels Ohio

OH

Significant Deficiency Internal Control / Segregation of Duties

Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its intern...

Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its internal control policies for payroll transaction cycle, which includes a review of all hours and rates by supervisors and the Executive Director. This occurs prior to the submission of payroll data to the Organization’s third-party payroll processor. An additional control procedure includes the review of changes made to the payroll system regarding new employees and any changes to pay rates.

View Audit 361433

Corrective Action Plans

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