Corrective Action Plans

Finding 1166335 (2025-002)

Material Weakness 2025

Brac Usa, Inc.

NY

Subrecipient Monitoring Reporting § 200.328

Views of Responsible Officials: In instances where Federal financial and programmatic reports were submitted after the due dates, delays were primarily driven by the time required to obtain and reconcile financial and programmatic data from subrecipients and to complete BRAC USA’s internal reviews a...

Views of Responsible Officials: In instances where Federal financial and programmatic reports were submitted after the due dates, delays were primarily driven by the time required to obtain and reconcile financial and programmatic data from subrecipients and to complete BRAC USA’s internal reviews and sampling procedures. While this resulted in late submissions, our priority was to ensure the completeness, accuracy, and integrity of reported information rather than compromising quality for timeliness. To strengthen compliance going forward, in any instance where BRAC USA anticipates a delay in submitting required Federal financial or programmatic reports, we will proactively communicate with donor or the pass-through entity in advance of the due date, explain the reasons for the delay (including any timing issues related to subrecipient data), and request written approval of a revised reporting deadline. This approach will help ensure transparency, maintain the donor’s ability to effectively monitor grant performance, and document mutual agreement on adjusted submission dates, while still allowing BRAC USA to complete the necessary review and reconciliation procedures to ensure accurate and reliable reporting. Planned Completion Date: December 31, 2025

View Audit 377413

Finding 1166334 (2025-001)

Material Weakness 2025

Brac Usa, Inc.

NY

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

Views of Responsible Officials: In practice, BRAC USA has consistently evaluated subrecipient risk prior to issuing subawards by considering factors such as prior experience with similar awards, historical audit results, organizational capacity, and financial stability. However, we acknowledge that ...

Views of Responsible Officials: In practice, BRAC USA has consistently evaluated subrecipient risk prior to issuing subawards by considering factors such as prior experience with similar awards, historical audit results, organizational capacity, and financial stability. However, we acknowledge that these assessments were not formalized or consistently documented in a standardized format, as required by 2 CFR § 200.332(c). To address this gap, BRAC USA will develop and implement written procedures and a standardized subrecipient risk assessment tool to be completed and filed prior to issuing Federal subawards. The tool will capture required criteria, including prior audit results, prior performance under similar awards, financial stability indicators, internal control considerations, and any recent staffing or systems changes. These procedures will be incorporated into BRAC USA’s Fiscal Policies and Procedures Manual. The results of each risk assessment will be used to tailor the level and nature of ongoing subrecipient monitoring, and records will be maintained in the grant file to evidence compliance with 2 CFR § 200.332(c). Planned Completion Date: April 30, 2026

View Audit 377413

Finding 1166263 (2025-003)

Material Weakness 2025

City Colleges of Chicago

IL

Subrecipient Monitoring Reporting § 200.303

Condition For one of the four reports tested for the Higher Education Institutional Aid Program, City Colleges did not timely submit a quarterly report to the Pass-Through Entity (PTE). A quarterly performance report was due on May 1, 2025 and submitted 14 days late on May 15, 2025. Cause Submission...

Condition For one of the four reports tested for the Higher Education Institutional Aid Program, City Colleges did not timely submit a quarterly report to the Pass-Through Entity (PTE). A quarterly performance report was due on May 1, 2025 and submitted 14 days late on May 15, 2025. Cause Submission delay was the result of miscommunication between PIs and the grantor. Corrective Action Taken or Planned The Institutional Resource Development (IRD) team will review all subaward grant contracts and work with the colleges to ensure that Tasks are entered into the Salesforce system to provide automatic two-week reminders to the PIs when performance reports are due to the pass-through entity (PTE). Contact Person: Lizz Gardner, Associate Vice Chancellor, Institutional Resource Development Anticipated Completion Date: January 31, 2026

View Audit 377334

Finding 1166261 (2025-002)

Material Weakness 2025

City Colleges of Chicago

IL

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was ...

Condition For one out of forty students tested, City Colleges properly recalculated a return of Title IV funds for a student but did not subsequently adjust the student's account to perform the return or notify the student of the adjusted award amount. Cause The lack of return of Title IV funds was an oversight due to human error. Corrective Action Taken or Planned To strengthen internal controls, the District Office assigned an analyst to conduct a review of a random selection of files across all seven colleges scheduled for audit to help identify any discrepancies early and ensure compliance. All R2T4 specialists will receive yearly refresher trainings on R2T4 procedures and controls. Contact Person: Leticia Garcia, District Director of Student Financial Aid Anticipated Completion Date: December 13, 2025

View Audit 377334

Finding 1166256 (2025-002)

Material Weakness 2025

Fremont County School District #1

WY

Special Tests & Provisions Subrecipient Monitoring

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action For future projects of this nature that are funded with federal dollars the District will implement a written procedure to ensure weekly certified payrolls are obtained, reviewed, and documented prior to payment approval. ...

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action For future projects of this nature that are funded with federal dollars the District will implement a written procedure to ensure weekly certified payrolls are obtained, reviewed, and documented prior to payment approval. The District will communicate these requirements to contractors and maintain a monitoring log going forward. Proposed Completion Date Fiscal year ended June 30, 2026

View Audit 377280

Finding 1166253 (2025-001)

Material Weakness 2025

Fremont County School District #1

WY

Subrecipient Monitoring Reporting

Name of Contact Person Travis Sweeney, SFO Business Manager Corrective Action In the future all supporting documentation will be retained by Business Office personnel and kept in the audit file. Proposed Completion Date Fiscal year ended June 30, 2026

View Audit 377280

Finding 1166225 (2025-001)

Material Weakness 2025

South Central Kansas Economic Development District, Inc.

KS

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking

Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, ...

Responsible party: Bethany Johnson, Interim Executive Director and Commercial Lending Manager and Tyler Ward, Interim Finance Director and Commercial Lender Implementation date: December 31, 2025 Corrective Action Plan Both Bethany Johnson, Interim Executive Director and Commercial Lending Manager, and Tyler Ward, Interim Finance Director and Commercial Lender, will continue to monitor the budget vs actuals both on a monthly and quarterly basis. Tyler Ward will provide an initial review and Bethany Johnson will provide a secondary review of the financial statements. If any variances are more than 5% over within a category, this category and the overall variances of each line item will be monitored closely to determine if any cumulative changes would cause a 10% or more increase or decrease overall in addition to a particular category. If a budget revision is determined to be required, Tyler Ward will prepare this document and Bethany Johnson will review and sign before submitting it to SBA. A reminder will be added to both Bethany Johnson and Tyler Ward’s SCKEDD calendars along with the existing reporting reminders. This will serve as a secondary reminder to monitor the budget at 90, 60 and 30 days before the end of the grant year. This will ensure that any changes in the 4th quarter can be addressed before the budget revision cutoff date to SBA. Calendar reminders will be added on 12/15/2025, and financials statement variances towards the Microloan grant will be reviewed with more scrutiny moving forward beginning with December 31, 2025 financial statements.

View Audit 377225

Finding 1166223 (2025-001)

Material Weakness 2025

Family Health Council of Central Pennsylvania, Inc.

PA

Cash Management Subrecipient Monitoring § 200.305

Corrective Action: The organization has enhanced its payment workflow to guarantee prompt disbursement of funds to providers. Improvements include automated alerts and internal checkpoints designed to prioritize payments immediately after grant funds are received. Anticipated Completion Date: Correc...

Corrective Action: The organization has enhanced its payment workflow to guarantee prompt disbursement of funds to providers. Improvements include automated alerts and internal checkpoints designed to prioritize payments immediately after grant funds are received. Anticipated Completion Date: Corrected.

View Audit 377221

Finding 1166213 (2025-001)

Material Weakness 2025

Tongore Pines Housing Developing Fund Co., Inc.

NY

Subrecipient Monitoring Eligibility HUD Housing Programs

Finding 2025-001. The management company is required to use the Enterprise Income Verification for eligibility determination per the compliance supplement. There are numerous reports required to be created and reviewed by management on a periodic basis. (1) Recommendation: The management company sho...

Finding 2025-001. The management company is required to use the Enterprise Income Verification for eligibility determination per the compliance supplement. There are numerous reports required to be created and reviewed by management on a periodic basis. (1) Recommendation: The management company should acquire access to the HUD EIV, and begin producing and reviewing the required reports within required timeframes. The organization should further establish procedures that will ensure ongoing compliance. These procedures should include training and monitoring of responsible staff. (2) Actions Taken: Management has worked with HUD to obtain access and will begin performing this responsibility. The appropriate reports will be produced and reviewed once management has access to the HUD EIV system. Procedures are being implemented to assure that this process is taking place.

View Audit 377193

Finding 1166211 (2025-002)

Material Weakness 2025

Heartland Medical Clinic, Inc., D/b/a Heartland Community Health Center

KS

Special Tests & Provisions Subrecipient Monitoring Eligibility

Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit...

Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2025. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the Revenue Cycle Manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper analysis and implementation of sliding fee discounts. o COO and Revenue Cycle Manager will review, implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and Revenue Cycle Manager.

View Audit 377177

Finding 1166203 (2025-001)

Material Weakness 2025

Holy Rosary Senior Residence Inc.

NJ

Subrecipient Monitoring HUD Housing Programs Significant Deficiency

Corrective Action Plan: Management agrees with the finding and will take steps to adjust the budget and ensure the R&R account is adequately funded moving forward. Anticipated Completion date: 07/14/2025

View Audit 377119

Finding 1166202 (2025-003)

Material Weakness 2025

City of Marine City

MI

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

RESPONSE: The practice of checking the debarment list had occurred in the past; the keeping of a "proof of practice" was not done. Going forward, this practice will be documented. TIMEFRAME FOR CORRECTIVE ACTION: Immediate. RESPONSIBLE CONTACT PERSON: Katy Posey, Financial Director/Treasurer

View Audit 377112

Finding 1166194 (2025-001)

Material Weakness 2025

Washington Maritime Blue

WA

Reporting Subrecipient Monitoring Significant Deficiency

Description: Significant deficiency in internal control over compliance related to reporting. Cause: Though the Organization has established internal controls for submitting covered subawards as required by the Transparency Act, the Organization made an incorrect determination that the covered subaw...

Description: Significant deficiency in internal control over compliance related to reporting. Cause: Though the Organization has established internal controls for submitting covered subawards as required by the Transparency Act, the Organization made an incorrect determination that the covered subaward was under the required reporting limit. Effect: The Organization did not comply with the subaward reporting requirements as specified in 2 CFR 170. Corrective Action: • The Organization’s management and Board of Directors understand the requirement and importance of complying with the Federal Funding Accountability and Transparency Act. Our Accounting & Finance Policy and Subrecipient Monitoring Policy have both been updated to clearly assign the responsibility for timely reporting of subawards. The covered subaward that was not reported in FY25 was reported promptly as soon as this issue was raised as part of the audit. Contact Person: Daniel Pulse, CFO Anticipated completion date: November 2025, Corrective action has been completed.

View Audit 377089

Finding 1166137 (2025-001)

Material Weakness 2025

Greater Washington Community Foundation

DC

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.303 § 200.332

The following actions will be taken to ensure compliance with the Uniform Guidance requirements over internal controls: Management concurs with the finding. Effective immediately, The Greater Washington Community Foundation has implemented the following corrective actions: (1) Prior to entering into...

The following actions will be taken to ensure compliance with the Uniform Guidance requirements over internal controls: Management concurs with the finding. Effective immediately, The Greater Washington Community Foundation has implemented the following corrective actions: (1) Prior to entering into any subaward agreement involving federal funds as well as at the time of each payment, designated staff will verify that potential subrecipients are not suspended or debarred by conducting searches in the System for Award Management (SAM) at www.sam.gov, with documentation maintained in the grant file. This verification will also be performed when subaward agreements are amended or extended. (2) The standard subaward agreement template will be updated to include all required information specified in 2 CFR §200.332(b)(1), including the federal assistance listing number, subrecipient's unique entity identifier, federal award project description, amount of federal funds obligated, total federal award amount, applicable compliance requirements, and reporting and monitoring requirements. To strengthen ongoing compliance, the Foundation's procurement and cash management policies have been updated to incorporate these federal compliance requirements and will be reviewed annually. Given that federal funding is not received on a recurring basis, upon receipt of future federal funding, the Controller will serve as the Compliance Coordinator with full oversight of compliance activities. The Controller will review applicable federal regulations, update internal procedures as necessary, and provide comprehensive training to appropriate staff managing the contract to ensure adherence to all grant requirements. The finance team will complete a quarterly review process to verify that all active federal subawards contain required compliance elements, with the Controller maintaining oversight of this review and reporting any deficiencies to the Chief Financial Officer for immediate remediation. Individual Responsible for Corrective Action Plan: Contact: Rachel Crawford Title: Controller Phone Number: 202-303-2437 Estimated Completion Date: December 31, 2025

View Audit 376968

Finding 1166099 (2025-002)

Material Weakness 2025

Lakefront Management Authority

LA

Reporting Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.502

The Authority will consider implementing the recommendation. The Authority is actively working on rectifying the finding.

View Audit 376868

Finding 1165916 (2025-002)

Material Weakness 2025

Pcc Community Wellness Center

IL

Subrecipient Monitoring

Recommendation: Management should consider increasing the frequency of its self-reviews of sliding fee encounters, increasing the frequency of when patient portal updates are being reviewed and approved, and/or provide additional training for front desk staff regarding the collection and verificatio...

Recommendation: Management should consider increasing the frequency of its self-reviews of sliding fee encounters, increasing the frequency of when patient portal updates are being reviewed and approved, and/or provide additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: See matrix below Name(s) of the contact person(s) responsible for corrective action: Hiren Patel, CFO Planned completion date for corrective action plan: See matrix below Finding 2025-002 / ACTION STEP 1 / ACTION STEP 2 / ACTION STEP 3 / ACTION STEP 4 Assigned / RCM Leaders / Executive Leaders / Patient Care Reps (PCRs) / Practice Managers / Enrollment Specialist/RCM Leaders Resources needed / Annual Federal Poverty Level (FPL) update issued no later than February of each year, given by federal government / Supporting financial documentation for all patients/applications / Athena (EHR system) / Audit tracking tools, EHR reports Actions to be taken / Audit EHR system to ensure timely update by EHR each year; updated internal QRG and distribute to Operations front-staff leaders and Compliance Update patient level amounts based on approval by Executive Leaders- as needed / Complete review of supporting financial documentation for each patient/application Upload documentation in EHR to support approval/disapproval-update EHR accordingly 85% collections of patient levels at time of service / Practice Manager Audits 25 SFS claims to ensure all documentation has been received, uploaded and reviewed accurately / Enrollment Specialist reviews patient account during self-pay collection efforts for all that have outstanding balances; ensures all have supporting documents aligning with approval, notifies RCM leaders monthly of inaccurate findings RCM Leaders audit 50-60 accounts quarterly to cover all sites Progress indicated at benchmark / Implement workflow / Implement workflow / Implement **NEW**Workflow / Implement workflow Completion date / February of each year / February 2026 / February 2026 / February 2026 Evidences of improvement / Reporting to ensure alignment / Monthly audit / Monthly audit / Monthly/Quarterly audit

View Audit 376823

Finding 1165866 (2025-001)

Material Weakness 2025

State of Hawaii Department of the Attorney General

HI

Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Action

View Audit 376771

Finding 1165866 (2025-001)

Material Weakness 2025

State of Hawaii Department of the Attorney General

HI

Subrecipient Monitoring

The Hawaii Criminal Justice Data Center (the HCJDC) will perform a desk review for its two

View Audit 376771

Finding 1165866 (2025-001)

Material Weakness 2025

State of Hawaii Department of the Attorney General

HI

Subrecipient Monitoring

subrecipients for grant number 202-NS-BX-K004 by June 30, 2026. The desk reviews will be performed

View Audit 376771

Finding 1165866 (2025-001)

Material Weakness 2025

State of Hawaii Department of the Attorney General

HI

Subrecipient Monitoring

virtually and will include a risk assessment and review of project performances and outcomes.

View Audit 376771

Finding 1165814 (2025-002)

Material Weakness 2025

Ocean View School District

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility

Immediate Corrective Action Taken: • Fiscal Services reviewed the Title I allocations to confirm that no improper fiscal impact occurred as a result of the reporting discrepancy. • The district documented the finding and communicated the error internally to Fiscal Services and Educational Services s...

Immediate Corrective Action Taken: • Fiscal Services reviewed the Title I allocations to confirm that no improper fiscal impact occurred as a result of the reporting discrepancy. • The district documented the finding and communicated the error internally to Fiscal Services and Educational Services staff. • Roles and responsibilities for ConApp enrollment data review have been clarified to prevent future manual errors. Preventive Measures to Avoid Recurrence: 1. Dual Verification of ConApp Enrollment Data • The Accountant in Fiscal Services will now compare and confirm the ConApp enrollment counts to certified CALPADS Fall 1 data before submission and certification. • A second-level review by the Coordinator of Teaching and Learning Department certifying the ConApp. 2. Documentation & Recordkeeping • Any adjustments to pre-populated enrollment numbers will require written justification and supporting documentation (e.g., CALPADS reports, email confirmations). Responsible Parties: • Fiscal Services Accountant – Responsible for matching the ConApp enrollment counts to CALPADS Fall 1 and maintaining backup documentation. • Coordinator, Teaching and Learning Department – Support in verifying site-level data. Completion Date: • Immediate clarification and assignment of review responsibilities were completed in October 2025.

View Audit 376684

Finding 1165813 (2025-001)

Material Weakness 2025

Ocean View School District

CA

Allowable Costs / Cost Principles Subrecipient Monitoring

Immediate Corrective Action Taken: • Upon discovery, the Ocean View School District Fiscal Services Department reclassified the payroll cost from Title I to the employees regular special education funding account. • This journal entry was completed prior to closing the books for FY 2024-25, ensuring...

Immediate Corrective Action Taken: • Upon discovery, the Ocean View School District Fiscal Services Department reclassified the payroll cost from Title I to the employees regular special education funding account. • This journal entry was completed prior to closing the books for FY 2024-25, ensuring that Title I funding was fully restored and not negatively impacted. Preventive Measure to Avoid Recurrence: Budget Code Verification Process • Fiscal Services has implemented an additional review step for all extra duty or abnormal pay requests. Before processing, HR and Payroll staff must verify the program code against the employee’s funding source in the financial system. Responsible Parties: • Director of Fiscal Services – Oversight of corrective action and monitoring. • Payroll Supervisor & HR Coordinator – Verification of funding sources before processing extra pay. • Site Administrators – Correct budget coding on memoranda. Completion Date: • Immediate correction was made prior to FY 2024-25 year-end close (August 19, 2025).

View Audit 376684

Finding 1165810 (2025-003)

Material Weakness 2025

Baraga Area Schools

MI

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

2025-003 – UNALLOWABLE COSTS Corrective Action Plan: The School District staff has subsequently reviewed all reimbursements under the Fresh Fruits and Vegetables Program grant and has repaid the funds to the Michigan Department of Education in the amount of $2,178.68. In the future when a new grant ...

2025-003 – UNALLOWABLE COSTS Corrective Action Plan: The School District staff has subsequently reviewed all reimbursements under the Fresh Fruits and Vegetables Program grant and has repaid the funds to the Michigan Department of Education in the amount of $2,178.68. In the future when a new grant is received, the School District will print the grant documents and review them with the necessary employees to ensure they are aware of the allowable and unallowable costs. Additionally, all invoices will be reviewed by the Food Service Director prior to being submitted to the business office for payment. Responsible Party(ies): • Food Service Head Cook Anticipated Completion Date: December 31, 2025

View Audit 376652

Finding 1165806 (2025-001)

Material Weakness 2025

Second Harvest Heartland

MN

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

Audit Finding: ALN: 10.565 Grant No.: 204642 Grant Period: Year ended September 30, 2025 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action:  Scanning Applications: o CSFP staff scan applications daily. These applications are t...

Audit Finding: ALN: 10.565 Grant No.: 204642 Grant Period: Year ended September 30, 2025 Type of finding – Significant deficiency in internal control over compliance Response: Agree Explanation/Corrective Action:  Scanning Applications: o CSFP staff scan applications daily. These applications are then stored in SharePoint. We have 2-3 volunteers weekly who rename applications based on Client ID, Name, and Expiration Date, then file them electronically based on their expiration date. This ensures that we are always up to date on having an electronic version of our CSFP applications. o Before shredding any applications that have been scanned, we confirm that the application exists in the system (done by CSFP staff).  If an application is missing: o Confirm that application information is in ClientTrack and document through a generated printed application. o Send application to distribution site for next distribution, to ensure participant signs new application before they receive another CSFP box. Anticipated Completion Date: This process was fully implemented at the end of May 2024. It should be noted that the applications have a 3-year certification period, so the full effect of the new process won’t be realized until spring of 2027.

View Audit 376643

Finding 1165796 (2025-001)

Material Weakness 2025

Kalkaska Public Schools

MI

School Nutrition Programs Subrecipient Monitoring

The Food Service Director will coordinate a check procedure to review monthly meal counts before submitting reimbursement from Michigan Department of Education. Contact person responsible for corrective action: Jenny Patton, Food Service Director, Anticipated Completion Date: 12/31/2025

View Audit 376591

Corrective Action Plans

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