Corrective Action Plans

Finding 1181747 (2024-002)

Material Weakness 2024

MI

Student Financial Aid Significant Deficiency

Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the foll...

Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the following process: When a recipient of Title IV grant or loan assistance withdraws from Eastern Michigan University and a Return of Title IV calculation is performed, a Senior Financial Aid Advisor or member of the Financial Aid Management staff will review all required returns completed to ensure accuracy. This review will occur on a weekly basis. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024

View Audit 393001

Finding 1181745 (2024-001)

Material Weakness 2024

Eastern Michigan University

MI

Student Financial Aid Reporting Significant Deficiency

Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to ver...

Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to verify that enrollment rosters will not be/have not been sent after a semester has officially ended. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024

View Audit 393001

Finding 1181473 (2024-008)

Material Weakness 2024

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Reporting Significant Deficiency Internal Control / Segregation of Duties

U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During ...

U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During our testing of performance and special reporting, we noted that the Organization did not maintain documentation evidencing review or approval of submitted reports. The reports tested did not include evidence demonstrating that an authorized individual reviewed and approved the performance and special reports prior to submission. Recommendation: The Organization should implement formal internal controls over performance and special reporting by establishing documented procedures that require review and approval of all reports prior to submission. Management should define clear roles and responsibilities for report preparation and independent review, ensure that reviews are performed by an authorized individual, and maintain documentation evidencing review and approval, such as signatures, dates, or electronic approvals, to support compliance with performance reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will implement formal internal controls over performance and special reporting by developing and documenting standardized procedures for the preparation, review, and approval of all required federal performance and special reports. These procedures will clearly define roles and responsibilities for report preparation and independent review, including identification of authorized individuals responsible for final approval. Evidence of review and approval—including signatures, dates, or electronic approval records—will be retained in the grant file to support compliance with reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2026.

View Audit 392710

Finding 1181456 (2024-006)

Material Weakness 2024

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Allowable Costs / Cost Principles Eligibility School Nutrition Programs

Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Seco...

Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. The Organization has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respectiveidentifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2026.

View Audit 392710

Finding 1181444 (2024-005)

Material Weakness 2024

Community Action Committee of the Lehigh Valley, Inc. and Subsidiaries

PA

Eligibility Subrecipient Monitoring Allowable Costs / Cost Principles

U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodit...

U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodities during fiscal year 2024. Recommendation: The Organization should prioritize the timely monitoring of participating agencies to allow for changes in food distributions if any ineligible participants are discovered. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization developed a schedule to complete monitoring and created a checklist to ensure that all documentation is in the appropriate folder. In addition, the organization began conducting internal audits to ensure the developed processes are being followed. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is May 2026.

View Audit 392710

Finding 1181377 (2024-005)

Material Weakness 2024

South Big Horn Hospital District

WY

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

2024-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2026.

View Audit 392624

Finding 1180823 (2024-002)

Material Weakness 2024

Porchlight, Inc.

WI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

Management agrees with the finding and has taken corrective action to ensure the timely completion and submission of the audit reporting package. With the implementation of Sage Intacct and the strengthening of internal accounting processes, Porchlight is now able to begin audit preparation earlier ...

Management agrees with the finding and has taken corrective action to ensure the timely completion and submission of the audit reporting package. With the implementation of Sage Intacct and the strengthening of internal accounting processes, Porchlight is now able to begin audit preparation earlier in the year. Regular monthly reconciliations and improved staff training have significantly reduced the number of adjustments required at year‐end. Financial statements will be prepared internally prior to the audit process, allowing management to review financial information earlier and provide complete information to the auditors in a timely manner. While certain reporting configurations within Sage Intacct continue to be refined, Porchlight is working with outside consultants experienced with the system to ensure reporting functionality operates effectively. Porchlight is also developing a formal year‐end close checklist and reporting calendar to ensure that all financial reporting tasks are completed on schedule and that audit preparation begins sufficiently in advance of reporting deadlines. The Finance Director, with oversight from the Executive Director, is responsible for monitoring audit timelines and, along with our auditors, ensure all deadlines for submission to the Federal Audit Clearinghouse are met. Staffing improvements and the engagement of external consultants have strengthened the organization’s capacity to complete the audit process in a timely manner. Management will continue to monitor internal timelines and reporting procedures to ensure future audit submissions are completed within required deadlines. Person(s) Responsible: Halle Pollay Timing for Implementation: In process

View Audit 392484

Finding 1179811 (2024-001)

Material Weakness 2024

Special Health Resources for Texas, Inc.

TX

Significant Deficiency Internal Control / Segregation of Duties Special Tests & Provisions

To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule...

To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.

View Audit 392189

Finding 1179640 (2024-003)

Material Weakness 2024

City of Rochester, New Hampshire

NH

Procurement, Suspension & Debarment Significant Deficiency Matching / Level of Effort / Earmarking § 200.327

Audit Finding Reference: SD-2024-003 Improve Internal Controls & Compliance with Procurement Planned Corrective Action: All contracts involving any federal grants will include the appropriate CRF 200 & 200.327 language. The language will be a required element of all federal contract, and will be cle...

Audit Finding Reference: SD-2024-003 Improve Internal Controls & Compliance with Procurement Planned Corrective Action: All contracts involving any federal grants will include the appropriate CRF 200 & 200.327 language. The language will be a required element of all federal contract, and will be clearly identified. No contracts will be approved by the City Manager without this language. Planned Implementation Date of Correction Action: Immediately as of date of deficiency notice 3-2-26. Person Responsbile for Corrective Action: Director of Finance

View Audit 392049

Finding 1179563 (2024-006)

Material Weakness 2024

Economic Action Committee of the Gulf Coast

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303 § 200.512

Finding 2024-006 - Late Submission of Data Collection Form Corrective Action Plan: Management will implement a formal compliance calendar to track Uniform Guidance reporting deadlines. Responsibility for submission will be assigned to a specific individual. Audit progress will be monitored regularly...

Finding 2024-006 - Late Submission of Data Collection Form Corrective Action Plan: Management will implement a formal compliance calendar to track Uniform Guidance reporting deadlines. Responsibility for submission will be assigned to a specific individual. Audit progress will be monitored regularly to ensure timely completion and submission of the reporting package and Data Collection Form. Additionally, management will address underlying financial reporting control weaknesses identified in this audit to improve overall audit readiness. Responsible Party: Executive Director, Board of Directors (oversight) Planned Completion Date: Compliance calendar implemented March 11, 2026; ongoing monitoring thereafter.

View Audit 391938

Finding 1179521 (2024-002)

Material Weakness 2024

Ida B Wells, INC

CT

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management has maintained appropriately trained and experienced personnel to ensure the financial close process has been completed accurately and timely.

View Audit 391894

Finding 1179434 (2024-003)

Material Weakness 2024

Bemidji Regional Airport Authority

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

Controls Over Reporting Federal Agency: U.S. Department of Transportation Federal Program Name: Airport Improvement Program Assistance Listing Number: 20.106 Federal Award Identification Number and Year: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49, 2024 Pass-Through Agency...

Controls Over Reporting Federal Agency: U.S. Department of Transportation Federal Program Name: Airport Improvement Program Assistance Listing Number: 20.106 Federal Award Identification Number and Year: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49, 2024 Pass-Through Agency: Minnesota Department of Transportation Pass-Through Numbers: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49 Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the Authority have a secondary person reviewing these reports before they are submitted to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will evaluate its internal staff capacity to determine if an internal control policy over reviews is beneficial. Name of the contact person responsible for corrective action: Kyle Christiansen, Executive Director Planned completion date for corrective action plan: December 31, 2025

View Audit 391841

Finding 1179127 (2024-003)

Material Weakness 2024

County of Hancock, Maine

ME

Significant Deficiency

Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.

View Audit 391523

Finding 1177955 (2024-003)

Material Weakness 2024

Western Montana Mental Health Center & Affiliate

MT

Reporting Significant Deficiency

WMMHC will implement additional review procedures for grant expenditures to ensure timely filing and compliance with federal requirements.

View Audit 391372

Finding 1177694 (2024-001)

Material Weakness 2024

Talmud Torah Darkei Avos - Monsey

NY

Internal Control / Segregation of Duties Reporting School Nutrition Programs

Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 sched...

Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 schedule of findings and questioned costs is discussed below. Finding 2024-001: Federal Awards Program Audit U.S. Department of Agriculture Child Nutrition Cluster Programs Deficiency: See Finding 2024-001 Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 05/31/2026 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end August 31, 2025. Mr. Yaakov Rotenberg, food service director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-2476. Contact Person Responsible for Corrective Action: Yaakov Rotenberg, Food Service Director

View Audit 391115

Finding 1177682 (2024-015)

Material Weakness 2024

Southeast New Mexico College

NM

Student Financial Aid Reporting Significant Deficiency § 200.512

Recommendation The College should continue to work with the accounting department and accounting systems to assist its auditor to catch up its financial reporting and records to allow for the completion of future audits. Corrective Action Unfortunately, due to the untimely completion and release of ...

Recommendation The College should continue to work with the accounting department and accounting systems to assist its auditor to catch up its financial reporting and records to allow for the completion of future audits. Corrective Action Unfortunately, due to the untimely completion and release of the June 30, 2023 audit report (released on August 8, 2025 - over two years after the end of the June 30, 2023 fiscal year audit), the College did not have the opportunity to review and begin a timely process of addressing a majority of the audit findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the June 30, 2023 audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. To ensure timely future submissions, the following corrective actions have been implemented. Revised Timeline and Calendar Controls: • A compliance calendar has been developed and integrated into the Business Office workflow to monitor federal reporting deadlines, including the DCF due date. This calendar includes reminder notifications at 90, 60 and 30 days before the March deadline. Internal Review Process: • A designated compliance officer or fiscal services staff member has been assigned responsibility for tracking the DCF submission process and coordinating with the external auditors to ensure timely receipt of the final audit. Audit Planning Coordination: • Annual audit planning meetings now include a discussion of reporting deadlines, and the contract with the external audit firm will include a clause requiring delivery of the final audit in a timeframe that supports compliance with federal submission timelines. Training and Awareness: • Relevant staff will have completed training in Uniform Guidance reporting requirements, including DCF submission procedures and deadlines to ensure full understanding of the importance of timely compliance. Due of Completion: August 31, 2025 Responsible Party(ies) Vice President for Business and Finance (or appropriate official), Dean of Business and Finance, Director of Finance, Accounts Receivable Coordinator, Business Office Manager

View Audit 391086

Finding 1177673 (2024-011)

Material Weakness 2024

Southeast New Mexico College

NM

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Significant Deficiency § 200.302 § 200.305

Recommendation We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs Management Response Corrective Action Unfortunately, due to the untimely completion and release of the June 30, 2023 audit repo...

Recommendation We recommend the College establish the required written procedures for federal monies and have them available to all personnel who work with federal programs Management Response Corrective Action Unfortunately, due to the untimely completion and release of the June 30, 2023 audit report (released on August 8, 2025 - over two years after the end of the June 30, 2023 fiscal year audit), the College did not have the opportunity to review and begin a timely process of addressing a majority of the audit findings until well after the end of the audit period. While the College is committed to corrective action, the delayed delivery of the June 30, 2023 audit limited the ability to implement corrective measures earlier. The College is working proactively to ensure that these issues are resolved going forward. It is important to note that Southeast New Mexico College was a newly established independent community college, having formally separated from New Mexico State University (NMSU) as of April 2022. During this transition period, many administrative processes, including federal grant compliance procedures, were in the process of being developed, transitioned, and implemented independently from NMSU systems. As a result, certain policies, procedures, and documentation processes were not yet fully established or operational at the time of the audit. Corrective Action Taken / Planned: Policy Development • The institution will develop comprehensive written policies and procedures to address compliance requirements related to 2 CFR 200, Subparts D and E of the Uniform Guidance and approved by institutional leadership by July 31, 2025. Policy Review and Approval • Draft policies will be reviewed by VP of Business and Finance and approved by institutional leadership by August 31, 2025. Training • Relevant personnel will be trained on the new policies and procedures to ensure consistent understanding and compliance. Implementation • The institution will fully implement the new procedures by August 31, 2025, and will ensure all departments involved with federal awards are following them. Ongoing Review: • Policies and procedures will be reviewed annually, and updates will be made as necessary to ensure continued compliance with federal regulations. Date of Completion: August 31, 2025 Responsible Parties Vice President for Business and Finance (or appropriate official), Dean of Business and Finance, Director of Finance, Restricted Funds Manager

View Audit 391086

Finding 1177606 (2024-002)

Material Weakness 2024

South Seven Senior Village

WA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that additional internal controls are required to ensure eligibility is verified, current, and fully documented prior to the provision of services. The instance identified resulted from a misinterp...

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that additional internal controls are required to ensure eligibility is verified, current, and fully documented prior to the provision of services. The instance identified resulted from a misinterpretation of system information and insufficient verification procedures to confirm current eligibility. In response, OlyCAP has initiated corrective actions to strengthen eligibility determination controls, including reinforcing documentation requirements prior to service initiation, clarifying staff procedures for reviewing eligibility system data, and providing additional training to ensure eligibility requirements are consistently understood and applied. Management is committed to maintaining compliance with federal program requirements and improving internal controls to prevent similar occurrences in the future. Estimated Completion Date: In progress / Ongoing Responsible Party: Program Management with Finance Oversight

View Audit 390989

Finding 1177605 (2024-001)

Material Weakness 2024

South Seven Senior Village

WA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that stronger internal controls over the single audit reporting process are necessary. During the audit period, the organization did not have sufficiently formalized procedures to ensure timely sub...

Management's Response: Olympic Community Action Programs (OlyCAP) acknowledges this finding and agrees that stronger internal controls over the single audit reporting process are necessary. During the audit period, the organization did not have sufficiently formalized procedures to ensure timely submission of the SF-SAC reporting package. Since identifying this issue, OlyCAP has begun implementing improved internal controls. During the first half of 2024, the department experienced the loss of all lead fiscal staff, which required subsequent corrections and adjustments to 2024 reporting once external consultants were engaged. This work occurred concurrently with the organization’s transition from antiquated systems to newer platforms. As part of the corrective actions, OlyCAP has established clearly defined responsibility for audit submissions, implemented internal deadlines that precede federal filing requirements, and strengthened management oversight to verify timely completion and submission. OlyCAP is committed to improving its internal control environment to ensure future single audit submissions are completed accurately and within required deadlines. Estimated Completion Date: Completed Responsible Party: Executive Director

View Audit 390989

Finding 1177006 (2024-003)

Material Weakness 2024

Smithfield Housing Authority

RI

HUD Housing Programs Reporting Significant Deficiency

The methodology used for sample selection will be documented and retained to ensure a clear audit trail and demonstrate that the sample was selected in an unbiased manner. Supervisory review of SEMAP certifications and supporting documentation will occur prior to submission to ensure compliance with...

The methodology used for sample selection will be documented and retained to ensure a clear audit trail and demonstrate that the sample was selected in an unbiased manner. Supervisory review of SEMAP certifications and supporting documentation will occur prior to submission to ensure compliance with 24 CFR Â§ 985 requirements. Training has been scheduled for April 7, 2026 which will help ensure that staff are aware of the requirements of SEMAP moving forward for its biennial reporting.

View Audit 390862

Finding 1176662 (2024-002)

Material Weakness 2024

Community Action Agency of Butte County, Inc.

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.302 § 200.303

Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distri...

Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distributed, used for on site meal preparation, and leftover items transferred to partner nonprofits—are supported by appropriate documentation. A standardized set of templates will be used to record: • Distribution logs at each location • Congregate Aggregate Feeding Reports • Documentation of leftover or transferred goods All documentation will be retained in a centralized repository accessible to program and compliance staff. ________________________________________ 2. Distribution Tracking Controls The Organization has implemented strengthened controls to ensure accurate and complete tracking of all food commodities. These controls include: • Required completion of distribution logs at all partner locations • Mandatory retention of Congregate Aggregate Feeding Reports • Reconciliation of monthly distribution activity to the Monthly Distribution Report • Documentation of discarded or transferred goods A compliance checklist is being developed to verify that all required documents are collected each month. ________________________________________ 3. Designation of Responsibility A Chief Operating Officer has been assigned responsibility for ensuring that all distribution documentation is collected, retained, and reviewed. Program staff and site partners will receive ongoing training to ensure consistent adherence to the updated tracking requirements. ________________________________________ 4. Review and Approval A formal review and approval process has been established. Monthly Distribution Reports will be reviewed by: • The Chief Operating Officer • The Warehouse Manager Any discrepancies or missing documentation will be investigated and resolved prior to monthly reporting. ________________________________________ 5. Monitoring and Follow Up Beginning in 2025, the Organization implemented ongoing monitoring procedures, including periodic internal audits of distribution files. Quarterly compliance reviews will be performed to assess adherence to documentation requirements and to identify additional training needs. The Warehouse Manager will report quarterly to senior leadership on distribution documentation compliance. Management will continue refining the new processes and providing ongoing training to ensure full, consistent adoption across all distribution sites. The Organization anticipates that these corrective actions will fully address the documentation gaps identified in the audit and strengthen internal controls moving forward. ________________________________________ Implementation Timeline All corrective action steps were initiated in 2025, and full implementation of updated procedures is ongoing. The Organization anticipates complete adoption across all distribution sites by December 31, 2026. ________________________________________ Responsible Personnel • Chief Operating Officer-Food Bank Operations: Thomas Deramore • Warehouse Manager-Food Bank Operations: Sean Conner • Chief Financial Officer: Kate Stefan • Executive Director: Timothy Hawkins ________________________________________ This Corrective Action Plan is designed to address the auditor’s findings, recommendations and prevent recurrence of similar issues to ensure compliance with Uniform Guidance documentation standards and internal control requirements ________________________________________ Signature: ________________________________________ Kate Stefan, Chief Financial Officer Community Action Agency of Butte County, Inc.

View Audit 390526

Finding 1176657 (2024-003)

Material Weakness 2024

Harrington Family Health Center

ME

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Finding: 2024-003 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115...

Finding: 2024-003 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $115 but qualified for a discount of $215, resulting in a $100 difference. Individual(s) Responsible for Corrective Action: Tafta McCain, Interim CEO, Fraction CFO – Community Link Consulting, Financial Team Planned Corrective Action: The Organization has revised its sliding fee discount policies and has established controls that streamline the path of sliding fee documentation from time of receipt to patient notification in a spreadsheet shared between front office, financial and billing staff. All pertinent documents are uploaded and hyperlinked to the spreadsheet for easy reference. The corrective action includes implementing quarterly supervisory reviews of sliding fee discounts, defining a sample size, and documenting corrective actions when errors are identified. Additional attention will be given to areas with greater manual processing, including Dental services. Staff training has been reinforced to ensure understanding of policy requirements, and management oversight will verify that monitoring procedures are performed consistently and documented appropriately. These actions will strengthen compliance with Section 330 requirements and reduce the risk of future inconsistencies. Anticipated Completion Date: Document tracking is in progress with quarterly review to begin in April 2026.

View Audit 390525

Finding 1176627 (2024-002)

Material Weakness 2024

Hopi Tribal Housing Authority

AZ

Reporting Significant Deficiency

Management Response: Management concurs with the finding. We recognize the importance of timely submission to the Federal Audit Clearinghouse (FAC) to ensure transparency and maintain eligibility for federal funding. Anticipated Completion Date: To prevent a recurrence, management is implementing th...

Management Response: Management concurs with the finding. We recognize the importance of timely submission to the Federal Audit Clearinghouse (FAC) to ensure transparency and maintain eligibility for federal funding. Anticipated Completion Date: To prevent a recurrence, management is implementing the following steps:  Audit Readiness Calendar: HTHA has prepared a Request for Proposal (RFP) for audit-services solicitation and will publicly post the RFP. The final award date will be Spring 2026. We will develop and implement a formal Standard Operating Procedure (SOP) by Spring 2026 to document the required frequency, format, and supporting documentation for all material reconciliations. The auditor engagement will be fully executed no later than June 2026. Mandatory staff training on the new reconciliation protocols will be conducted for all accounting personnel by Spring 2026, to reinforce accountability and technical proficiency. Responsible Party: Finance Director (responsible party for the significant deficiency), and Chief Financial Officer (CFO) (responsible for internal control implementation).

View Audit 390475

Finding 1176372 (2024-006)

Material Weakness 2024

Central Community Transit

MN

Reporting Significant Deficiency Equipment & Real Property Management

2024-006 UNIFORM GUIDANCE AUDIT REPORTING REQUIREMENTS Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota...

2024-006 UNIFORM GUIDANCE AUDIT REPORTING REQUIREMENTS Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota Department of Transportation Pass-Through Number: MN-2020-020-01, MN-2023-045-00 Award Period: Year Ended December 31, 2024 Compliance Requirement: Property and Equipment Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: Equipment acquired under federal awards needs to have proper maintenance of records including description, source of funding, who holds title, acquisition date, cost, percentage of Federal agency participation in the cost, location, use and condition, and any disposition data. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Transit Board will continue to work on the maintenance of records for property and equipment acquired under federal awards. Name of the contact person responsible for corrective action: Cecilia Mutharia, Transit Director Planned completion date for corrective action plan: June 30, 2026

View Audit 390191

Finding 1176370 (2024-004)

Material Weakness 2024

Central Community Transit

MN

Cash Management Reporting Significant Deficiency § 200.303

2024-004 INTERNAL CONTROLS OVER CASH MANAGEMENT Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota Depart...

2024-004 INTERNAL CONTROLS OVER CASH MANAGEMENT Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota Department of Transportation Pass-Through Number: MN-2020-020-01, MN-2023-045-00 Award Period: Year Ended December 31, 2024 Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Controls over Compliance Recommendation: It is recommended the Transit Board designate qualified personnel for conducting the quarterly reporting review. The review should be performed and documented. Formal procedures should be documented to ensure consistency and effectiveness of the quality review process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Transit Board will continue to evaluate their internal staff capacity to determine if an internal control policy over cash management and other areas is beneficial. Name of the contact person responsible for corrective action: Cecilia Mutharia, Transit Director Planned completion date for corrective action plan: June 30, 2026

View Audit 390191

Corrective Action Plans

Filters