Corrective Action Plans

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

Special Tests & Provisions Subrecipient Monitoring Eligibility § 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

Special Tests & Provisions Subrecipient Monitoring Eligibility

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

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 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

Finding 1158202 (2024-002)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...

Finding No. 2024-002 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): Nassau County Condition: During our testing, we noted that the Organization did not provide the required monthly reports to Nassau County. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158201 (2024-001)

Material Weakness 2024

National Council for Community Development, Inc.

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

Finding No. 2024-001 - Procurement, Suspension and Debarment - Material Weakness Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not a...

Finding No. 2024-001 - Procurement, Suspension and Debarment - Material Weakness Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): City of Irving Condition: During our testing, we noted that the Organization did not provide adequate supporting documentation for ensuring proper suspension and debarment checks were performed. Recommendation: We recommend that the Organization establish written suspension and debarment policies and procedures to ensure that the Organization is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Management has clarified the necessary roles and responsibilities for this requirement in our grant compliance and administration policies and procedures that includes appropriate searches for suspension and debarment, amongst others. prior to executing any financial transactions with individuals and/or organizations. Anticipated completion date: Immediately.

View Audit 370110

Finding 1158174 (2024-002)

Material Weakness 2024

Washington Tourism Alliance

WA

Subrecipient Monitoring Reporting Significant Deficiency

FINDING 2024-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance The grant contract conditions require that applicable reports be filed quarterly. State of Washington Tourism initially submitted performance reports monthly, but in Q4 of 2024 adju...

FINDING 2024-002 – Reporting; Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance The grant contract conditions require that applicable reports be filed quarterly. State of Washington Tourism initially submitted performance reports monthly, but in Q4 of 2024 adjusted the performance reports to quarterly in accordance with award agreement timeframe. The Accounting Manager will complete the report and provide documented support at the end of each quarter in the future. The reports will be reviewed, approved, and submitted by the Director of Strategic Partnership and Tourism Development. These changes took effect April 2025.

View Audit 370086

Finding 1158147 (2024-001)

Material Weakness 2024

Western States Information Network, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency

Corrective Action: To prevent further incidents, WSIN plans to revise its written accounting procedures to strengthen internal control policies on subaward monitoring and the requirements of the FFATA reporting. Also, with the FFATA reporting now residing in SAM.gov, WSIN will have immediate access ...

Corrective Action: To prevent further incidents, WSIN plans to revise its written accounting procedures to strengthen internal control policies on subaward monitoring and the requirements of the FFATA reporting. Also, with the FFATA reporting now residing in SAM.gov, WSIN will have immediate access to directly input all necessary subaward information. There will be no more waiting periods or delays for the subaward information to be auto loaded or accessed.

View Audit 370070

Finding 1158129 (2024-002)

Material Weakness 2024

Lansing Economic Area Partnership, Inc.

MI

Procurement, Suspension & Debarment Subrecipient Monitoring

2024-002 – Documentation of Controls over Suspension and Debarment (Repeat Finding) Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment, Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery...

2024-002 – Documentation of Controls over Suspension and Debarment (Repeat Finding) Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Procurement, Suspension and Debarment, Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Description of Condition and Effect. During our testing of suspension and debarment for three vendors and six subrecipients, it was determined that the Organization did not verify that vendors or subrecipients were not suspended, debarred or otherwise excluded when the Organization contracted with them to provide goods or services for five of the nine vendors and subrecipients. The searches at www.sam.gov were done in early 2025 by management, which was well after the date of the applicable contractual agreement and expenditure activity. The failure to monitor suspension and debarment could cause funds to be disbursed to vendors or subrecipients who are not eligible to have goods and services purchased with federal monies. Auditor Recommendation. We recommend that the Organization retain documentation of their procurement process including checking vendors for potential exclusions from federal award work. We further recommend that these checks be done prior to entering into a contractual agreement. Corrective Action. LEAP will be following the recommendation of retaining all documentation of our procurement process including the checking of vendors both at state and federal levels for any potential exclusions from federal award work, and ensuring these checks be done prior to contract execution. LEAP will be substantially modifying its procurement policy that is part of its Grants Management SOP in order to more explicitly detail expectations and procedural steps to meet the requirements of Uniform Guidance with regards to sequence of events leading up to contract execution, including the state and federal checks for exclusion. Further, LEAP’s leadership will be holding a module within the aforementioned internal training for all management team members to walk through a new check list tool that aligns with policy and Uniform Guidance, and case study exercise will also hit on this topic to ensure learning occurs around the internal controls improvements made with policy revamp. Responsible Person. Tony Klisch, LEAP CFO Anticipated Completion Date. August 31, 2025

View Audit 370048

Finding 1158128 (2024-001)

Material Weakness 2024

Lansing Economic Area Partnership, Inc.

MI

Subrecipient Monitoring

2024-001 – Lack of Subrecipient Monitoring Activities Finding Type. Immaterial Noncompliance/Material Weakness in Internal Control over Compliance (Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Descr...

2024-001 – Lack of Subrecipient Monitoring Activities Finding Type. Immaterial Noncompliance/Material Weakness in Internal Control over Compliance (Subrecipient Monitoring). Program. Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, All Awards. Auditor Description of Condition and Effect. Six subrecipients were selected for testing during the audit procedures. There was no subrecipient agreement noted for one of the subrecipients selected, therefore the required federal award information was not properly communicated. Additionally, no risk assessment was performed, nor was a monitoring plan within documentation of monitoring activities noted for this subrecipient. For the remaining five subrecipients selected for testing, the required federal award information was not properly communicated within the agreements. Lastly, the Organization does not have a procedure requiring the review of subrecipient audits. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Auditor Recommendation. We recommend that management become familiar with the subrecipient monitoring requirements and draft a policy and procedures that provide reasonable assurance that future subrecipient arrangements will be in compliance with the Uniform Guidance. Corrective Action. In an effort for LEAP to become more familiar with the subrecipient monitoring requirements and drafting policy and procedures that provide assurance that future subrecipient arrangements will be in full compliance with the Uniform Guidance federal regulations, LEAP will be modifying its Grants Management SOP to more explicitly detail expectations and procedural steps to meet the requirements of Uniform Guidance. Further, LEAP’s leadership will be holding an internal training for all management team members to discuss this revamped set of policies, go through case study exercises and question and answer session to make sure that all those managing grants or the employees that manage grants have a full understanding of what is expected of them, and their role in various management and oversight processes for the organization. Responsible Person. Tony Klisch, LEAP CFO Anticipated Completion Date. August 31, 2025

View Audit 370048

Finding 1158125 (2024-003)

Material Weakness 2024

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement po...

Description of Finding: The Foundation and its affiliates did not ensure proper documentation was retained regarding its procurement process. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will adopt a procurement policy in accordance with UGG 2 CFR 200.318 through 200.327 and will collaborate more closely with project partners of federal grants to ensure documentation requirements for the procurement process are adhered to and work to centralize grant documentation for all awards. This will be in tandem with establishing effective internal controls as per Uniform Guidance 2 CFR 200.303. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and centralization of grant documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158124 (2024-002)

Material Weakness 2024

Tulsa Community Foundation

OK

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate more closely ...

Description of Finding: The Foundation and its affiliates did not ensure proper performance reporting was completed for individual grants. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will collaborate more closely with project partners of federal grants to establish reporting deadlines and monitor individual reporting requirements throughout the year. This will be in tandem with establishing effective internal controls as per UGG 2 CFR 200.303. The Foundation will take steps to ensure that all required reports are submitted in a timely manner and all relevant documentation and evidence of reports’ submissions are retained in an effective manner. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158123 (2024-001)

Material Weakness 2024

Tulsa Community Foundation

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.303

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more ...

Description of Finding: The Foundation did not have effective internal control policies in place to ensure proper compliance with the federal awards. Statement of Concurrence or Nonconcurrence: Tulsa Community Foundation agrees with this finding. Corrective Action: The Foundation will create a more in-depth federal award process and collaborate with project partners to ensure their understanding of the compliance requirements as per Uniform Guidance (UGG) 2 CFR 200.303. The Foundation will also begin internal monitoring to ensure project partners are following established policies and procedures through the duration of each award. To support this corrective action, the Foundation has hired an experienced senior accountant to strengthen internal capacity. The qualified senior accountant will oversee federal grants and ensure ongoing compliance with internal controls and help to prevent recurrence of the issue. Name of Contact Person: Kristin Karlin, Controller Projected Completion Date: The Foundation projects the new policy documentation to be complete and the process for internal monitoring documentation to be established by December 31, 2025.

View Audit 370045

Finding 1158051 (2024-002)

Material Weakness 2024

Semo Electric Cooperative

MO

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-002 Noncompliance: Activities Allowed/Unallowed; Allowable Costs/Activities; Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by s...

2024-002 Noncompliance: Activities Allowed/Unallowed; Allowable Costs/Activities; Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management concurs. Large fiber installation project still in process at year-end. Subsequent reconciliations have been completed. Controls and other project processes have been improved to ensure more timely reconciliation of material charge-outs to the timing of the installation of material. Anticipated completion date: Completed Contact information for this finding: Amanda Burnett, Chief Financial Officer, 573-471-5821

View Audit 369998 Questioned Costs: $1

Finding 1158050 (2024-001)

Material Weakness 2024

Semo Electric Cooperative

MO

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness

2024-001 Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management...

2024-001 Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management concurs. Large fiber installation project still in process at year-end. Subsequent reconciliations have been completed. Controls and other project processes have been improved to ensure more timely reconciliation of material charge-outs to the timing of the installation of material. Anticipated completion date: Completed Contact information for this finding: Amanda Burnett, Chief Financial Officer, 573-471-5821

View Audit 369998

Finding 1158022 (2024-002)

Material Weakness 2024

Center for Black Excellence and Culture

WI

Procurement, Suspension & Debarment Subrecipient Monitoring

2024-002 Procurement Documentation Retention Corrective Action Plan The Center for Black Excellence and Culture Inc will obtain procurement documentation for all vendors and keep for our records electronically in our shared google drive folders. We will have the board review and approve a criteria f...

2024-002 Procurement Documentation Retention Corrective Action Plan The Center for Black Excellence and Culture Inc will obtain procurement documentation for all vendors and keep for our records electronically in our shared google drive folders. We will have the board review and approve a criteria for RFP evaluation and a procurement policy. Person(s) Responsible: Jason Fields, Chief Operations Officer Timing for Implementation: No later than December 31, 2025

View Audit 369989

Finding 1158020 (2024-002)

Material Weakness 2024

Young Women's Christian Association of Kalamazoo, Michigan

MI

Questioned Costs Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grant...

Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grants, the Organization was unable to provide enrollment forms or supporting documentation. These forms are necessary to verify that participants met the program's eligibility criteria. YWCA Response- The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - Procedures exist to ensure all clients are enrolled and eligible for services under the STOP grant. In addition to documentation in the Apricot system, an additional legal screening process and intake forms are used to determine eligibility and complete client enrollment within a Victim Services application called MyCase. During the audit, documentation for the four identified cases from MyCase was erroneously excluded, causing the finding. As a subsequent event, the documentation for intake and eligibility for the four identified cases was provided to the external auditors. This process will continue, and future audits will include client documentation for both systems. Additionally, Enforcement of enrollment procedures within Apricot, and oversight from department Directors, has been made a priority. Time Frame for Correction -Appropriate procedures were in place during the full audit year of 2024 and will continue into future years. Corrective action related to documentation within the Apricot system was implemented in August 2025. Individuals Responsible - Jessica Glynn, Vice President of Victim Services and Kellie Swikoski, Grant Manager.

View Audit 369986 Questioned Costs: $1

Finding 1158005 (2024-001)

Material Weakness 2024

Humanity & Inclusion

MD

Subrecipient Monitoring Reporting

Views of Responsible Officials: The delay resulted primarily from turnover within the grants management team and the concurrent implementation of a new subaward monitoring system during the reporting period. These factors temporarily affected the timely completion and review of FFATA submissions. To...

Views of Responsible Officials: The delay resulted primarily from turnover within the grants management team and the concurrent implementation of a new subaward monitoring system during the reporting period. These factors temporarily affected the timely completion and review of FFATA submissions. To address the issue and prevent recurrence, HI has taken the following corrective actions: 1. Process Strengthening: Internal grants management procedures have been updated to include a detailed FFATA reporting checklist and a pre-submission timeline that allows for earlier internal review. 2. Staff Training: All grants and compliance staff received refresher training in February 2025 on FFATA reporting requirements and internal deadlines. 3. Oversight and Monitoring: The Director of Grants and Compliance will review FFATA submissions monthly to ensure adherence to Federal reporting deadlines. HI is committed to maintaining full compliance with Federal requirements and will continue to monitor the effectiveness of these corrective measures throughout the current fiscal year.Anticipated Completion Date: February 2025 (with ongoing monthly monitoring throughout the current fiscal year). Responsible Official: Hannah Guedenet, U.S. Executive Director.

View Audit 369979

Finding 1157969 (2024-004)

Material Weakness 2024

Iclei – Local Governments for Sustainability Usa, INC

MI

Subrecipient Monitoring § 200.332

2024-004 - Subrecipient Monitoring Activities Auditor Description of Condition and Effect: During subrecipient monitoring testing, the ALN number and award number were not included in the four subrecipient agreements subjected to testing. Additionally, the Organization does not have a policies/proce...

2024-004 - Subrecipient Monitoring Activities Auditor Description of Condition and Effect: During subrecipient monitoring testing, the ALN number and award number were not included in the four subrecipient agreements subjected to testing. Additionally, the Organization does not have a policies/procedure in place to evaluate and address subrecipient's fraud risk and risk of noncompliance. Auditor Recommendation: We recommend that the Organization adopt additional policies and procedures related to subrecipient monitoring to ensure compliance with Uniform Guidance. Corrective Action: The Organization will implement stronger control in place to ensure that subrecipient disclosure requirements are included in the subrecipient agreements. In addition, the Organization will put in place a formal policy to address subrecipient fraud risk and risk of noncompliance. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025

View Audit 369971

Corrective Action Plans

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