Corrective Action Plans

Finding 1159852 (2024-006)

Material Weakness 2024

MN

Cash Management Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.

View Audit 370389

Finding 1159836 (2024-007)

Material Weakness 2024

Second Harvest Northern Lakes Food Bank

MN

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.

View Audit 370389

Finding 1159800 (2024-003)

Material Weakness 2024

City of Akron, Ohio

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.

View Audit 370339 Questioned Costs: $1

Finding 1159799 (2024-002)

Material Weakness 2024

City of Akron, Ohio

OH

Subrecipient Monitoring Material Weakness Reporting § 200.208 § 200.328

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

View Audit 370339

Finding 1159736 (2024-002)

Material Weakness 2024

Okaloosa Aids Support and Informational Services INC Dba Oasis Florida

FL

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...

Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.

View Audit 370319

Finding 1159707 (2024-005)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Cash Management Subrecipient Monitoring § 200.303 § 200.305

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...

U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25

View Audit 370288

Finding 1159706 (2024-004)

Material Weakness 2024

County of Luzerne, Pennsylvania

PA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

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

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

View Audit 370288

Finding 1159679 (2024-001)

Material Weakness 2024

Greater Seacoast Community Health

NH

Subrecipient Monitoring Special Tests & Provisions Significant Deficiency

To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that inc...

To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.

View Audit 370266

Finding 1159675 (2024-004)

Material Weakness 2024

Lane Council of Governments

OR

Subrecipient Monitoring Reporting § 200.331 § 200.332 § 200.510

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

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

View Audit 370264

Finding 1159641 (2024-003)

Material Weakness 2024

Town of Dauphin Island

AL

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.302

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers ...

The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers using the new due-to due-from procedures. In addition, our staff is currently researching a variety of software programs in order to strengthen our in-house grant management procedures to maintain full compliance. The Town will also consider hiring additional personnel and/or soliciting the services of a professional grant manager to further assist with future grant opportunities, particularly those involving grant funds.

View Audit 370259

Finding 1159640 (2024-001)

Material Weakness 2024

Tmc Healthcare

AZ

Reporting Questioned Costs Subrecipient Monitoring § 200.328

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

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

View Audit 370254

Finding 1159584 (2024-001)

Material Weakness 2024

Franklin County Technical School District

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...

Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.

View Audit 370226 Questioned Costs: $1

Finding 1159583 (2024-001)

Material Weakness 2024

Loretto Rest Realty Corporation

NY

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs

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

View Audit 370224

Finding 1159572 (2024-002)

Material Weakness 2024

Toole County

MT

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.

View Audit 370216

Finding 1159475 (2024-003)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Subrecipient Monitoring

Management will amend each subaward agreement to include all required identifying award information, including the allocation of state and federal funds to the award.

View Audit 370210

Finding 1159464 (2024-001)

Material Weakness 2024

Chaffee County

CO

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303 § 200.319

The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.

View Audit 370208

Finding 1159439 (2024-001)

Material Weakness 2024

Montefiore Health System, Inc.

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring § 200.303

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...

Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.

View Audit 370177

Finding 1159427 (2024-001)

Material Weakness 2024

Coastal Community Action Program

WA

Reporting Subrecipient Monitoring § 200.302

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

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

View Audit 370154

Finding 1159421 (2024-001)

Material Weakness 2024

Brooklyn Plaza Medical Center, Inc.

NY

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

View Audit 370146

Finding 1159406 (2024-008)

Material Weakness 2024

Mount Sinai Health System, Inc.

NY

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...

Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. Due to a system failure, vendor payment files from January through September 2024 were not transmitted to Mount Sinai’s sanction screening vendor. Mount Sinai has taken corrective actions to address this issue. All current vendors in our vendor master file, as well as all new vendors added through our new vendor credentialing process, are now processed through our sanction screening vendor on a monthly basis. In addition, a new manual control has been implemented to review, confirm, and reconcile to ensure that the vendor master file has been transmitted successfully, and all vendors are screened for sanctions, and a report thereof is provided each month. Our process will also document and maintain evidence that unverified vendors or those that were indicated as excluded were investigated and evaluated by the Health System. We will also periodically perform independent sanction screening checks on a sample of our vendors to validate the accuracy of the results of our third-party sanction screening vendor. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our vendor credentialing process was establishing with our ERP implementation on October 7, 2024. Our enhanced procedures to reconcile our file transmissions to our independent third-party and perform screening checks on samples of vendors verified by our independent third-party is expected to be implemented by December 31, 2025.

View Audit 370128 Questioned Costs: $1

Finding 1158286 (2024-005)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring § 200.208 § 200.303 § 200.328 § 200.329

Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely subm...

Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely submission and retention of supporting documentation for required sponsor reporting. This process will be implemented by December 31, 2025.

View Audit 370126

Finding 1158250 (2024-003)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Questioned Costs

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information techn...

Management acknowledges the findings related to compliance with GLBA requirements. The missing elements were primarily due to existing policies and procedures not specifically covering the information technology system utilized by the School of Nursing. Management will update their information technology policies and procedures to ensure full compliance with the 7 required elements outlined by the GLBA. This will include updating risk assessment procedures, designing safeguards based on risk assessments procedures, monitoring these safeguards, and documenting the results. These policy and procedure updates will be implemented by December 31, 2025.

View Audit 370126

Finding 1158246 (2024-001)

Material Weakness 2024

Providence St. Joseph Health

WA

Subrecipient Monitoring Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...

Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.

View Audit 370126

Finding 1158233 (2024-001)

Material Weakness 2024

Hawaii Public Health Institute

HI

Subrecipient Monitoring Questioned Costs Reporting

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the sub...

Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the subrecipient's name, subaward date, and subaward amount on SAM.gov website prior to the completion of this federal grant, which ended on June 30, 2025. The funder confirmed receipt of our reporting and did not specify any implications for late submission. As recommended by the auditors, HIPHI has developed a process to help identify the subawards subject to the FFATA reporting requirements prior to the start of the grant, and to ensure that reporting is reviewed, approved for completeness and accuracy, and filed in a timely manner. The Director of Finance, Finance and Accounting Manager, Program Managers and contract signers will be responsible for implementing these corrective actions by the end of 2025.

View Audit 370124

Finding 1158209 (2024-002)

Material Weakness 2024

Jesuit Refugee Service/usa, INC

DC

Subrecipient Monitoring

Finding: Subrecipient Single Audits. The Organization’s grant and subgrant agreements explicitly require subgrantees to undergo a single audit if they expend $750,000 or more in a fiscal year, as stipulated by the Department of State. However, audits were not performed for subgrantees exceeding this...

Finding: Subrecipient Single Audits. The Organization’s grant and subgrant agreements explicitly require subgrantees to undergo a single audit if they expend $750,000 or more in a fiscal year, as stipulated by the Department of State. However, audits were not performed for subgrantees exceeding this threshold in Cameroon, South Sudan, and Iraq. This non-compliance was caused by failures in the subrecipient control monitoring process. Corrective Action Plan JRS/USA recognizes the risk presented when Country Offices (COs) or Regional Offices (ROs) are unable to meet audit requirements, particularly when receiving U.S. federal funds. While JRS/USA does not have direct authority to mandate CO/RO audits in all regions, we recognize our responsibility to ensure federal compliance across the global network. To address this, JRS/USA will implement a stricter due diligence and pre-award assessment process. Specifically, going forward, COs/ROs must demonstrate the ability to meet audit and financial reporting requirements as a condition for receiving federal funding. If these requirements are not met, JRS USA will take corrective action, which may include suspending their inclusion in federal awards until compliance can be assured. JRS/USA will also revisit the previously proposed “go/no-go” framework and explore its formal adoption as part of a broader compliance risk management strategy. To address this gap and strengthen subrecipient oversight related to audit compliance, JRS/USA is implementing the following measures: 1. Reinforced Audit Clause Communication JRS/USA has reviewed and re-communicated the audit requirements to all subrecipients (country offices), particularly those with high federal expenditures. Subgrantees are being reminded annually in writing of their obligation to procure a Single Audit or Program-Specific Audit if they meet the $750,000 threshold. 2. Enhanced Subrecipient Monitoring Process The subrecipient monitoring framework has been updated to include: a) Annual tracking of total federal expenditures by each subrecipient (country office) b) Flagging of subrecipients approaching the $750,000 threshold c) A review checkpoint at year-end to determine audit applicability d) Clear documentation requirements and timelines for submitting audit report 3. Audit Compliance Checklist and Tracker A standardized checklist has been created to track audit requirements and receipt of audit documentation from all subrecipients (country offices). This checklist is maintained centrally by the JRS/USA compliance or grants team and reviewed quarterly. 4. Technical Support to Subrecipients Subrecipients (country offices) that may lack familiarity with the Single Audit requirement are being offered guidance and support on: a) Identifying qualified auditors b) Understanding scope and timing of required audits c) Budgeting for audit costs appropriately 5. Subaward Risk Assessments Updated The risk assessment conducted during subaward issuance and annual monitoring now includes specific indicators for federal expenditure levels and audit compliance risk. This ensures earlier detection and mitigation for high-risk subrecipients. Timeline for Implementation All corrective actions have been implemented or will be fully in effect by January 30, 2026. Responsible Party Samira Ahmed, Senior Grants and Compliance Specialist, will be responsible for ensuring subrecipient audit compliance and ongoing monitoring.

View Audit 370111

Corrective Action Plans

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