Corrective Action Plans

Finding 367 (2023-001)

None 2023

Jessie Trice Community Health System, Inc.

FL

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.317 § 200.318 § 200.327

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implem...

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

View Audit 770

Finding 319 (2023-001)

Significant Deficiency 2023

Community Action for Improvement, Inc.

GA

Significant Deficiency Internal Control / Segregation of Duties

CAFI's membership committee drives the recruitment process. The committee will meet again to discuss the plan to fill empty seats. The board and committee is actively recruiting to fill all seats.

View Audit 608

Finding 312 (2023-002)

Significant Deficiency 2023

Heyworth Community Unit School District No. 4

IL

Questioned Costs Equipment & Real Property Management Internal Control / Segregation of Duties

There is no disagreement with the audit finding. The District’s Grants Manager will collaborate to ensure all program equipment and property purchases exceeding $500 involving federal monies are appropriately tracked.

View Audit 587 Questioned Costs: $1

Finding 246 (2023-002)

Significant Deficiency 2023

Neighborhood Health Center, Inc.

IN

Procurement, Suspension & Debarment Significant Deficiency

Response: The Organization agrees with the finding and will develop a separate procurement policy for use with all federal award expenditures that contains the specific requirements by the Uniform Guidance. Carrie Miles, Chief Executive Officer, will oversee the implementation of this new policy by ...

Response: The Organization agrees with the finding and will develop a separate procurement policy for use with all federal award expenditures that contains the specific requirements by the Uniform Guidance. Carrie Miles, Chief Executive Officer, will oversee the implementation of this new policy by September 30, 2023.

View Audit 489

Finding 119 (2023-002)

Significant Deficiency 2023

Health Services, Inc.

AL

Special Tests & Provisions Eligibility Significant Deficiency

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining ...

The area of compliance evaluated relates to the area of organizational workflow that includes patient intake. Due to the severity of this issue, management has implemented the following as a corrective action: Contact granting organization for technical assistance with implementing and maintaining compliance during a period of increased staffing shortages and turnovers  Redesigned current workflow and office procedures to include the following changes: o Entry Level intake will only involve information gathering and collection of copays o 1st Level Supervision will review data and determine eligibility of sliding fee and application o 2nd Level Supervision will perform random chart audits Monthly o 3rd Level Supervisor will perform random chart audits Quarterly  All patient intake staff will receive one-on-one training on Sliding Fee and the importance of documentation.

View Audit 152

Finding 1206170 (2022-006)

Material Weakness 2022

Native Village of Barrow

AK

Allowable Costs / Cost Principles Significant Deficiency

Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss o...

Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.

View Audit 398166

Finding 1179151 (2022-006)

Material Weakness 2022

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Cash Management School Nutrition Programs Significant Deficiency

Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024

View Audit 391539

Finding 1175934 (2022-004)

Material Weakness 2022

Head Start of Lane County

OR

Significant Deficiency Internal Control / Segregation of Duties

Head Start of Lane County has created a timeline in partnership with Wipfli to ensure the completion of delinqunet audits and to ensure timely completion after August 31, 2026

View Audit 389901

Finding 1174933 (2022-018)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Eligibility Internal Control / Segregation of Duties HUD Housing Programs § 200.303

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...

Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174931 (2022-016)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Allowable Costs / Cost Principles Material Weakness Significant Deficiency § 200.303

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...

Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174927 (2022-014)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Equipment & Real Property Management Matching / Level of Effort / Earmarking Procurement, Suspension & Debarment § 200.303

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...

Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174926 (2022-013)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Subrecipient Monitoring Reporting Allowable Costs / Cost Principles § 200.303

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174836 (2022-004)

Material Weakness 2022

Insight Chicago, Inc.

IL

Allowable Costs / Cost Principles Reporting Significant Deficiency § 200.303

Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...

Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.

View Audit 388400

Finding 1173236 (2022-001)

Material Weakness 2022

New Space Nexus

NM

Eligibility Reporting Significant Deficiency

Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9...

Response: Management concurs with the finding. Corrective Action Plan: Management will implement and document a formal employee onboarding procedure that requires timely completion and retention of Form I-9 for all new hires. Existing personnel files will be reviewed for completeness and missing I-9 forms will be remediated where permissible. Management will retain evidence of completion and conduct periodic compliance reviews to ensure ongoing adherence. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by January 31, 2023.

View Audit 386730

Finding 1172717 (2022-009)

Material Weakness 2022

Northwest Indian College

WA

Subrecipient Monitoring Cash Management Significant Deficiency § 200.303 § 200.305

Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be es...

Recommendation: We recommend that the College review and update current procedures to ensure subrecipient payments are paid timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflows will be established between Grant PI's and the Accounts Payable department to ensure that subrecipient payments are submitted and paid timely. These workflows will be included in the Accounts Payable procedures. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Finding 1172706 (2022-008)

Material Weakness 2022

Northwest Indian College

WA

Eligibility Reporting Significant Deficiency § 200.303 § 200.328 § 200.329

Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...

Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Finding 1172705 (2022-005)

Material Weakness 2022

Northwest Indian College

WA

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

Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...

Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024

View Audit 385956

Finding 1172699 (2022-006)

Material Weakness 2022

Northwest Indian College

WA

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking § 200.317 § 200.318 § 200.326

Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are ...

Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

View Audit 385956

Finding 1168941 (2022-001)

Material Weakness 2022

New Directions, Inc.

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

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 381458

Finding 1166292 (2022-006)

Material Weakness 2022

Rehoboth McKinley Christian Health Care Services, Inc.

NM

Reporting Significant Deficiency

All required PRF reporting has been submitted. Will comply should new or additional reporting requirements be added in the future.

View Audit 377383

Finding 1166291 (2022-005)

Material Weakness 2022

Rehoboth McKinley Christian Health Care Services, Inc.

NM

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Eligibility § 200.302

Management will enforce existing internal control procedures and train staff to maintain appropriate documentation.

View Audit 377383

Finding 1166168 (2022-003)

Material Weakness 2022

City of Watertown

MA

Allowable Costs / Cost Principles Significant Deficiency

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented...

Date: 12/11/2025 Re: Corrective Action Plan - Audit Finding 2022-03 - Improve controls and documentation over allowability of costs Planned Corrective Action: The District will strengthen internal controls over allowability by implementing an allowability verification checklist, requiring documented approval for all grant-funded purchases, and maintaining adequate supporting documentation. Time and effort reporting processes will be reinforced. Grant monitoring procedures will include periodic allowability reviews. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature Ms. Emilys Peña Assistant Superintendent Dr. Deanne Galdston Superintendent of Schools Ms. Lisa Gibbons Director of Finance and Operations Dr. Ceronne Daly Director of Diversity, Equity, Inclusion, and Belonging Dr. Kathleen Desmarais Director of Student Services Ms. Amanda Owens Director of Human Resources

View Audit 377065

Finding 1165690 (2022-002)

Material Weakness 2022

California Labor Federation

CA

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.510

During the grant agreement review and signature process, the source of funding is identified and confirmed with the funder. As a result, when the Schedule of Expenditures of Federal Awards (SEFA) is developed, the source of funds has already been correctly identified.

View Audit 376394

Finding 1165685 (2022-001)

Material Weakness 2022

California Labor Federation

CA

Reporting Significant Deficiency § 200.512

Corrective Action Plan The books are now being closed within a few months after year-end. Once prior-year audits are brought current, audits will be completed annually within six months of the end of the fiscal year. All outstanding single audits are anticipated to be completed by February 28, 2026.

View Audit 376394

Finding 1164948 (2022-001)

Material Weakness 2022

Eastern Kentucky PRIDE, Inc.

KY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.

View Audit 374899

Corrective Action Plans

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