Corrective Action Plans

Finding 1172381 (2024-001)

Material Weakness 2024

HOUSING AUTHORITY OF THE CITY OF STERLING, COLORADO

CO

Cash Management HUD Housing Programs Subrecipient Monitoring

In accordance with HUD requirements, the Authority plans to begin drawing down operating-subsidy funds on a monthly basis. The Executive Director and Board will continue to review monthly financial statements prepared by the accountants and will research and evaluate potential investment options to ...

In accordance with HUD requirements, the Authority plans to begin drawing down operating-subsidy funds on a monthly basis. The Executive Director and Board will continue to review monthly financial statements prepared by the accountants and will research and evaluate potential investment options to increase the return on available funds. The Authority intends to develop and adopt formal written procedures for cash management and investment monitoring during the next fiscal year.

View Audit 385431

Finding 1172356 (2024-004)

Material Weakness 2024

1890 Universities Foundation

DC

Subrecipient Monitoring § 200.303 § 200.330

Finding 2024-004: Significant Deficiency and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the finding. We acknowledge the importance of adhering to the Federal guidelines for the submission of the reporting package within the mandated nine-mo...

Finding 2024-004: Significant Deficiency and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the finding. We acknowledge the importance of adhering to the Federal guidelines for the submission of the reporting package within the mandated nine-month period. This finding is a result of the transition in the accounting team. To address this, the 1890 Universities Foundation will implement the following actions: 1. Policies and Procedures Development: We will create and enforce comprehensive policies and procedures to ensure that audits are initiated and completed promptly. This will include detailed timelines and checkpoints to monitor progress throughout the audit process. In addition, we will adhere to a year end closing process that reconciles all significant accounts. 2. Training for Grant Administration: We will provide training for individuals responsible for administering federal assistance programs within the 1890 Universities Foundation. This training will cover essential aspects of grant administration, ensuring that our team is well-equipped to manage these programs efficiently and in compliance with federal requirements. Planned Implementation Date of Corrective Action Plan December 2025 Person Responsible for Corrective Action Plan Dr. Felecia Nave, Chief Executive Officer & President Natésha Johnson, Director of Finance and Administration

View Audit 385388

Finding 1172319 (2024-004)

Material Weakness 2024

Bristol Bay Borough, Alaska

AK

Subrecipient Monitoring Material Weakness Reporting

Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and tim...

Finding 2024-004: Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Name of Contact Person: Courtney Hoiby, Interim Finance Director Corrective Action Plan: New controls are being put into place to ensure that all subawards over $30,000 are properly and timely reported. Completion Date: September 30, 2026

View Audit 385350

Finding 1172271 (2024-006)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Subrecipient Monitoring Procurement, Suspension & Debarment Material Weakness § 200.301 § 200.328 § 200.329 § 200.334

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environ...

Finding 2024-006 – Compliance; Internal Control over Compliance, Reporting (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of AgricultureFederal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Under 2 CFR 200, recipients must submit performance and financial reports as required by the terms and conditions of the award and must retain records sufficient to demonstrate compliance (see (§200.301Monitoring and reporting program performance, and §200.328 Financial reporting, §200.329 Monitoring and reporting program performance, and §200.334 Retention requirements for records). The grant agreements for awards above require timely submission of performance / progress reports by specified due dates, with documentation maintained to support the submitted information. Condition: For the fiscal year ended June 30, 2024, the auditee could not provide sufficient evidence that required reports for the programs listed were prepared, reviewed, and submitted in accordance with grant terms. Specifically:  No provided required financial reports, and Partnership for the Umpqua Rivers lacked copies or evidence of submission, and support for reported amounts requested.  Auditors were not provided with performance/progress reports and were instructed that Partnership for the Umpqua Rivers had no retained copies, review sign-offs, or submission confirmation.  Where payments were received, support for the required reports or metrics were not retained and could not be supplied to auditors for reconciling to underlying records. Cause: Management has not implemented formal reporting controls, including:  A documented reporting calendar with due dates and responsible staff,  Reconciliation of report amounts to the accounting records,  Retention procedures for report copies, underlying support, and submission confirmations, and  Supervisory review evidenced by signatures or workflow approvals. Effect or Potential Effect: Absent evidence of timely, accurate reporting and adequate record retention:  The organization is at risk of noncompliance with federal award conditions,  Inaccurate financial or performance information may be reported to the funding agency, and  The entity may be subject to remedial actions, including heightened monitoring, repayment of questioned amounts, or potential suspension of funding. Questioned Cost: None directly noted, but potential risk if reports were incomplete or inaccurate.Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. Award files provided to auditors did not contain information related to reporting of activity, expenditures, or progress of the awards. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Establish a formal reporting and retention policy aligned with 2 CFR 200 and grant terms.  Implement a centralized reporting calendar that tracks due dates, preparers, reviewers, and submission methods.  Require reconciliations of financial reports to the general ledger and supporting schedules, retain the reconciliation with the reporting package.  Create standard workpapers for performance metrics for each award.  Configure the grant portal or document management system to retain submission confirmations, reports, receipts, and version -controlled copies of all reports for awards.  Document supervisory review through sign-offs prior to submission and with evidence retained.  Provide training to staff on Uniform Guidance requirements and record retention (§200.334). District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: ____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _____________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172217 (2024-004)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.302 § 200.303

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Env...

Finding 2024-004 – Insufficient Skills, Knowledge and Training, and Leadership (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation Service Assistance Listing Numbers: 10.905 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land ManagementCriteria: Under Uniform Guidance 2 CFR §200.303, non-federal entities must establish and maintain effective internal control over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the award terms and conditions. This includes ensuring that:  Personnel administering federal awards possess adequate skills, knowledge, and experience.  Management and leadership provide appropriate oversight of federal award activities.  Financial management systems adequately support accurate reporting, documentation, retention, and reconciliation of federal expenditures in accordance with 2 CFR §200.302. Condition: During the audit of federal awards, the entity did not demonstrate sufficient skills, knowledge, or experience of the staff and leadership responsible for administering and overseeing federal programs. Specifically:  Adequate supporting documentation for federal award expenditures was not maintained or provided.  Leadership oversight of federal award compliance activities was limited, and management review of grant activity were not evidenced. These conditions resulted in weaknesses in financial reporting, compliance monitoring, and documentation related to federal awards. Cause: Partnership for the Umpqua Rivers has not ensured that staffing levels, qualifications, and experience are sufficient to support federal award administration and compliance. In addition, leadership lacks adequate knowledge of federal award requirements to provide effective governance, oversight, and monitoring of compliance activities. Formal training and documented procedures for federal awards management have not been prioritized. Effect or Potential Effect: As a result of these deficiencies:  Partnership for the Umpqua Rivers is at increased risk of non-compliance with Uniform Guidance requirements.  Federal expenditures may be unsupported, inaccurately reported, or unallowable.  Errors or compliance violations may not be detected or corrected in a timely manner.  The entity may be subject to questioned costs, repayment of federal funds, or additional scrutiny from grantor agencies. Questioned Cost: None identified Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit. Recommendation: We recommend that Partnership for the Umpqua Rivers:  Ensure staff responsible for federal awards receive appropriate training on Uniform Guidance requirements, grant financial management, documentation, and compliance monitoring. Assign federal award oversight to personnel with sufficient experience and qualification or obtain external grant management and accounting support as needed.  Establish written policies and procedures for federal award administration, including expenditure documentation, reconciliation, compliance review, and management approvals.  Require leadership to perform and document periodic oversight and monitoring of federal awards, including review of reconciliations reimbursement requests, and compliance metrics.  Implement ongoing monitoring and internal control assessments to ensure compliance with federal award requirements. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: ___________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172190 (2024-003)

Material Weakness 2024

Partnership for the Umpqua Rivers

OR

Reporting Subrecipient Monitoring § 200.302 § 200.303 § 200.430

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Enviro...

Finding 2024-003 – Lack of Internal Controls over Expenditure Documentation (Material Weakness) Name of Federal Agency: U.S. Environmental Protection Agency Federal Program Name: Nonpoint Source Implementation Grants Assistance Listing Numbers: 66.460 Pass-Through Entity: Oregon Department of Environmental Quality Name of Federal Agency: U.S. Department of Commerce – National Oceanic and Atmospheric Administration Federal Program Name: Pacific Coast Salmon Recovery Program Assistance Listing Numbers: 11.438, 15.015, 15.244 Pass-Through Entity: State of Oregon – Oregon Watershed Enhancement Board (OWEB) Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: National Fish and Wildlife Foundation Assistance Listing Numbers: 10.665 Pass-Through Entity: U.S. Forest Service Name of Federal Agency: U.S. Department of Agriculture Federal Program Name: Natural Resources Conservation ServiceName of Federal Agency: U.S. Department of the Interior Federal Program Name: Wildlife, Sport Fish and Restoration Program Assistance Listing Numbers: 15.244 Pass-Through Entity: Bureau of Land Management Name of Federal Agency: U.S. Department of the Interior Federal Program Name: Secure Rural Schools and community Self-Determination – Watershed and water-quality improvements Assistance Listing Numbers: 15.234 Pass-Through Entity: Bureau of Land Management Criteria: Title 2 CFR §200.303 requires nonfederal entities to establish and maintain effective internal control over federal awards that provides reasonable assurance that the entity is managing the awards in compliance with federal statutes, regulations, and the terms and conditions of the award. Additionally, 2 CFR §200.302(b)(3) requires entities to maintain records that adequately identify the source and application of funds, including supporting documentation for expenditures, and 2 CFR §200.430 requires documentation for compensation for personal services. Condition: During our review of expenditures charged to the federal programs, the entity was unable to provide invoice copies or other sufficient supporting documentation for certain expenditures tested. As a result, we could not verify the allowability, accuracy, and proper approval of these costs in accordance with federal requirements. In addition, records were unavailable for Personnel expenditures that were charged to grant awards, and no support or evidence of time per grant was available. Cause: Partnership for the Umpqua Rivers does not have effective internal controls in place to ensure that invoice documentation and other supporting records are retained, centrally filed, and readily available for audit and monitoring purposes. In addition, management did not perform ongoing monitoring to verify that required documentation was maintained prior to reimbursement or reporting. Effect or Potential Effect: because supporting documentation was not available, expenditures from detail documentation could not be substantiated. This increases the risk that the unallowable, unsupported, or inaccurate costs may be charged to the federal program and reported in the Schedule of Expenditures of Federal Awards (SEFA). Questioned Cost: Yes, $332,409 related to Personnel costs, equipment and other purchases that were not documented with detailed support. Context: During our audit, it was found that the Partnership for the Umpqua Rivers experienced complete staff turnover in Financial Management for the year being audited. No current finance employees had worked for the organization during the year being audited. No financial files for Accounts Payable, invoices, or reporting were available to the current financial staff. Not adequately retaining supporting documents and invoices to support the expenditures of the general ledger and requests for reimbursement for grants, the organization records may be insufficient for testing and review, for internal controls or meeting federal documentation and reporting requirements. Repeat of a Prior-Year Finding: No, Prior- year did not require a Single Audit.Recommendation: Partnership for the Umpqua Rivers should implement policies and procedures requiring invoice copies and supporting documentation to be maintained for all grant expenditures. Management should strengthen record retention practices, provide training to staff on documentation requirements, and implement periodic internal reviews to ensure compliance. District Response: Partnership for the Umpqua Rivers acknowledges the deficiencies. Corrective Action Plan: _____________ (To be completed by Partnership for the Umpqua Rivers) Planned Implementation Date: _________ Responsible Person: Partnership for the Umpqua Rivers Finance Manager

View Audit 385339

Finding 1172086 (2024-006)

Material Weakness 2024

Housing Authority of the City of Conway

AR

Subrecipient Monitoring HUD Housing Programs Reporting

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address mis...

Action Taken: Management acknowledges the findings and the material weakness in internal control and material noncompliance in SEMAP reporting. We accept responsibility for the deficiencies in internal control over SEMAP reporting and are committed to implementing corrective actions that address missing self-certification documentalion to ensure compliance. The Authority must take immediate steps to remediate these deficiencies by establishing a robust, auditable documentation process: • Strengthen Internal Controls: Develop procedures to ensure complete and accurate documentation is maintained for all 14 SEMAP indicators, including detailed sampling methodologies. • Pre-Certification Review: Implement a mandatory management review process for all SEMAP documentation before final certification is submitted to HUD. • Ensure Proper Retention: Enforce document retention policies that align with HUD regulations, ensuring records are accessible for audit purposes. • Staff Training: Provide training to staff regarding SEMAP indicator requirements and the necessity of maintaining supporting evidence. • Utilize PIG Reports: Ensure all tenant data is properly reported in PlC, as this is the basis for several indicators. Name of Responsible Person: Catherine Lamberg, CEO, and Jackie Otto, COO, and Daporsha Abernathy, HCVP Director Projected Completion Date: Most of the corrective activities are completed. We anticipate completing the balance of activities by May 1, 2026.

View Audit 385225

Finding 1171930 (2024-001)

Material Weakness 2024

Sexual Assault Victim Advocate Center

CO

Internal Control / Segregation of Duties Subrecipient Monitoring

Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational ﬁnancial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated ﬁn...

Planned Corrective Action: Prior to the completion of the 2024 Audit, SAVA Center’s Executive Director began revising and updating the organizational ﬁnancial policies. These policies have been reviewed by the SAVA Center Finance Committee and voted for approval on January 16th, 2026. The updated ﬁnancial policies now contain detailed information on the segregation of duties, which now includes the following people: The Director of Operations (in-house bookkeeper and preparer of grant invoices), the contract Accountant (allocates payroll, prepares monthly ﬁnancial statements, and assists with preparing the organization budget), the Executive Director (signer of checks, holder of bank card, reviews all grant invoices prior to submission, monitors revenue/expenses, and monthly ﬁnancials), and the Board Treasurer (reviews and presents monthly ﬁnancials, signing authority, chairs the ﬁnance committee, and provides opinion when needed on accounting best practices). Name of Contact Person: Alison Jones-Lockwood, Executive Director Anticipated completion date: January 16, 2026

View Audit 384965

Finding 1171926 (2024-012)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Internal Control / Segregation of Duties Subrecipient Monitoring

2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-012 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Program's financial accounting system, it was noted that the Food Program utilizes QuickBooks software for their accounting system. Based on inquiry with CBS Food Program management, we determined internal controls connected with their QuickBooks accounting software were insufficient in the following areas: • User Access Management: Formal written policies or procedures have not been developed and implemented related to access authorization, access monitoring, and removal of system access. Additionally, certain functions are not properly segregated as users have access to perform both input and authorization of transactions. • Input Management: Formal written policies or procedures to ensure information input into QuickBooks is appropriate and accurate have not been developed and implemented. • Change Control Management: A formal written change management policy for QuickBooks Accounting System has not been developed and implemented including requirements that system security updates are implemented timely. • Backup and Recovery: A formal written policy for regular backup and recovery testing has not been developed and implemented. Recommendation: We recommend that CBS Food Program develop and implement comprehensive written internal control policies and procedures connected with their QuickBooks Accounting System. This should include: • Development and utilization of an Accounting Manual which includes an outline of CBS Food Program's accounting rules, procedures, and guidelines. • Access control policies and procedures to ensure that user access to QuickBooks is appropriate, regularly reviewed and promptly revoked upon termination or when otherwise merited. Recommendation (Continued) • A formal written change management policy for QuickBooks should be developed and implemented including requirements that systems security updates are implemented timely. • A disaster recovery plan and procedures to perform periodic testing to ensure that plans are functional and mitigate the risk of extended downtime. This process should also include regular review of backup records to ensure they are appropriately created and maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions does not dispute this finding. Community Benefit Solutions will migrate from Quickbooks Desktop to Quickbooks Online, which will provide a perfect transitional opportunity to re-evaluate processes, and to develop and implement necessary controls over its systems. Community Benefit Solutions will work with independent auditors, internal information technology team, and, if necessary, legal counsel to plan, draft, and implement the relevant internal controls. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171924 (2024-010)

Material Weakness 2024

Community Benefit Solutions

PA

Procurement, Suspension & Debarment School Nutrition Programs Internal Control / Segregation of Duties

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-010 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on interviews by the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (“Commonwealth”) with CBS Food program management, inspection of records, and on-site observations, we identified internal control deficiencies in the following areas: • For a portion of the audit period, there was a lack of segregation of duties between the cash receipt, bookkeeping, and bank reconciliation processes. The Director of Finance was responsible for all these tasks. The Director of Finance was also responsible for both processing and approving payroll and had authorization to make purchases, make vendor payments, record accounting transactions and complete bank reconciliations. • CBS Food Program performs bank reconciliations; however, they are not signed or dated by the individual performing the reconciliation and a second individual does not review or sign off on the reconciliations. Of nine reviewed account reconciliations, three were completed more than 30 days after the statement period end date. • According to CBS Food Program's former Purchasing Distribution Manager, as of June 2024, they were the only CBS Food Program's employees with detailed knowledge of developing monthly menus and creating purchase orders based on current inventory levels to meet menu requirements. Additionally, the former Purchasing Distribution Manager stated that as of June 2024 formal training on internal purchasing policies and procedures is not provided or required. Condition (Continued) • For a portion of the engagement period, CBS Food Program lacked written policies or procedures for several key business functions including: o No written Accounting Manual or Standard Operating Manual for accounting functions. o No written policy or procedure for the use of credit cards or the handling of lost or stolen credit cards. o No written policy or procedure to analyze account balances to ensure transactions have been properly recorded. o No written records retention policy. o No written procedures for handling payroll for separating employees. o No written or implemented review process for changes to the payroll system including changes to employee payrates. o For a portion of the engagement period, the Food Program did not have procedures to o Prior to July 1, 2024, CBS Food Program did not have documented procurement procedures. On July 1, 2024, CBS Food Program implemented a procurement plan. Recommendation: If not already addressed, CBS Food Program should develop and implement improved internal controls including: • Develop written policies, procedures and/or manuals for accounting functions. • Develop a formal internal control policy and framework that focuses on key business and operations areas including segregation of duties, transaction review and approval processes, and monitoring procedures over critical operational functions. • Improve cross training of employees including training on purchasing and accounting tasks. • CBS Food Program should develop and implement a record retention policy that complies with food program requirements for maintaining documentation of operations. The policy should ensure key records are maintained in a shared location accessible to all appropriate personnel. This ensures the CBS Food Program does not lose access to key records in the event an employee leaves the food program. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions will work with its outside independent audit firm, Board-approved counsel, and other necessary stakeholders to develop and implement all the necessary controls as required by the Comptroller. Community Benefit Solutions' implementation of any of the noted changes will be the ability to recruit Finance Committee and Nutrition Committee members of the Board. Moreover, Community Benefit Solutions made strides in implementing some of the requested policies during the Audit. Community Benefit Solutions will endeavor to meet each of the requests despite any lack of human capital that would allow for ease of segregation of authority. Community Benefit Solutions is optimistic that incoming Board Members and external accounting, audit, HR, and legal will provide critical support. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171922 (2024-007)

Material Weakness 2024

Community Benefit Solutions

PA

Subrecipient Monitoring School Nutrition Programs Internal Control / Segregation of Duties § 200.332

2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 C...

2024-007 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of subrecipient monitoring activities for PDE programs CACFP, NLSP, and SFSP, we selected 31 contracted centers at random. Management provided documentation for each site, including contracts, meal pattern usage records, licensure and training documentation, and both announced and unannounced meal observation reviews. However, we found that CBS Food Program did not always maintain sufficient evidence to prove required monitoring was performed under the CACFP program. For one center, management could not produce proof that meal observation reviews or the mandated two unannounced visits occurred. At another center, neither a contract nor any meal observation review records, including the two required unannounced visits, could be provided. For the NLSP and SFSP, management was unable to provide contracts for any of the seven sampled centers. Additionally, there was no evidence of training for one center, and a second center had a noncompliant monitoring visit; although corrective action was prepared, follow-up occurred only after 66 days instead of within the required 45-day window. Recommendation: We recommend that management strengthen internal controls to ensure all required PDE CACFP, NLSP and SFSP subrecipient monitoring activities, including scheduled meal observations and the mandated unannounced visits—are consistently performed, documented, and retained. Management should implement a centralized tracking system to monitor review deadlines, required follow up actions, and receipt of supporting documentation from each contracted center. In addition, staff responsible for monitoring should receive periodic refresher training on PDE CACFP, NLSP and SFSP specific expectations. Finally, management should conduct periodic internal reviews to verify that monitoring documentation is complete, compliant, and appropriately maintained. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Community Benefit Solutions shall utilize internally developed Quickbase application to schedule and track monitoring visits including ensuring necessary corrective action follow-ups are conducted within 45 days documented corrective action needed. Moreover, Community Benefit Solutions will require all monitoring staff to successfully complete monitoring specific training in addition to the annual and civil rights training to ensure up to date knowledge of all requirements. Trainings will be assigned, monitored and signed off on by Director of Operations. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171920 (2024-005)

Material Weakness 2024

Community Benefit Solutions

PA

Eligibility Internal Control / Segregation of Duties Subrecipient Monitoring

2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving me...

2024-005 Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: During our testing of participant eligibility, we selected a sample of 40 participants receiving meals at centers contracted with the CBS Food Program. For 2 of the 40 participants, management was unable to provide complete and valid eligibility documentation. In one instance, the only available eligibility form had been prepared in a future fiscal year, and in another instance, the eligibility form could not be located at all. Recommendation: We recommend that management strengthen its CACFP eligibility documentation procedures to ensure that all required forms are properly completed, collected, and retained for every participant. This should include implementing a standardized intake process, maintaining timely reviews to confirm completeness of eligibility files, and developing a tracking or monitoring system to identify missing or outdated documentation. Management should also reinforce internal expectations for timely updating of eligibility files and ensure staff are trained on CACFP documentation requirements. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: On February 1, 2025, Community Benefit Solutions rolled out the KidKare software system wide. KidKare is a CACFP software that allows Community Benefit Solutions to digitally process all eligibility-documentation, standardize the enrollment procedures, ensure forms are completed in accordance with the relevant regulations, request updated documentation upon the expiration of enrollment forms, and digitally store all the eligibility related information for all participants. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171914 (2024-008)

Material Weakness 2024

Community Benefit Solutions

PA

School Nutrition Programs Subrecipient Monitoring Material Weakness § 200.327 § 200.328 § 200.334

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirem...

2024-008 Material Weakness in Internal Control over Compliance The Child Nutrition Cluster: 10.555 – National School Lunch Program and 10.559 – Summer Food Service Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: As part of the reporting requirements for the CBS Food Program under the National School Lunch Program (NSLP) and Summer Food Service Program (SFSP), management is responsible for submitting the FNS 10 (NSLP) and FNS 418 (SFSP) reports within 30 days after month-end. However, management was unable to provide five (5) monthly NSLP reports and one (1) monthly SFSP report requested for audit testing. Recommendation: The Organization should establish and enforce strengthened internal controls over federal reporting to ensure that all required monthly reports (FNS 10 and FNS 418) are: (a) completed accurately, (b) submitted on time, and (c) retained in accordance with federal record retention requirements (2 CFR 200.334). Management should designate responsible personnel and implement a monitoring process to ensure compliance. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: Effective, July 1, 2024, Community Benefit Solutions no longer administers the National School Lunch Program. In the event Community Benefit Solutions should begin administering the NSLP, Community Benefit Solutions will develop and implement requisite policies and procedures to ensure proper reporting requirements including, but not limited to, completion and submission of the FNS10. Planned completion date for corrective action plan: June 30, 2025

View Audit 384963

Finding 1171884 (2024-003)

Material Weakness 2024

Heart of Georgia Regional Airport Authority

GA

Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

THE BOARD WILL DOCUMENT THE PROCUREMENT PROCEDURES FOR FEDERAL AWARDS AND SUBAWARDS.

View Audit 384866

Finding 1171869 (2024-006)

Material Weakness 2024

Municipality of Loiza

PR

Subrecipient Monitoring Reporting Significant Deficiency § 200.339

The Municipality Administration is currently addressing the control and compliance issue. Starting on January 2026 prior year reports will be submitted. Full compliance expected to start on January 2026 going forward.

View Audit 384837

Finding 1171868 (2024-005)

Material Weakness 2024

Municipality of Loiza

PR

Subrecipient Monitoring Internal Control / Segregation of Duties Reporting § 200.339

All monthly reports were delivered on time to AFAAF as established on the guidelines and following the agency’s reporting guidelines and support. The Municipality is full compliance with the Puerto Rico Fiscal Agency and Financial and Financial Advisory Authority

View Audit 384837

Finding 1171708 (2024-015)

Material Weakness 2024

Osage County

OK

Subrecipient Monitoring § 200.332

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developi...

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developing a comprehensive SOP to ensure accurate and timely tracking and reporting of Federal funds, • improving communication and oversight between all county offices to ensure consistent reporting standards, • and ensuring annual compliance with federal reporting requirements. Our collective goal is to implement the policies and structures that will keep Osage County operating with the highest standard of accountability and excellence County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on Grants and Awards. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.

View Audit 384731

Finding 1171707 (2024-014)

Material Weakness 2024

Osage County

OK

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.1 § 200.329 § 200.344

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developi...

Chairman of the Board of County Commissioners: This issue originated under the prior County Clerk’s administration where key reporting processes were not followed. The Board of County Commissioners and the other elected officials have made correcting this a top priority. Together, we are: • developing a comprehensive SOP to ensure accurate and timely tracking and reporting of federal funds, • improving communication and oversight between all county offices to ensure consistent reporting standards, • and ensuring annual compliance with federal reporting requirements. Our collective goal is to implement the policies and structures that will keep Osage County operating with the highest standard of accountability and excellence. County Clerk: I was not the County Clerk in office at this time. To correct this issue. the County plans to develop a SOP to timely and accurately track and report on federal funds. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners. County Treasurer: The County was under the understanding that once we established we were reporting as Loss Revenue, we would not have to submit the report annually. The final reporting was submitted prior to deadline.

View Audit 384731

Finding 1171705 (2024-012)

Material Weakness 2024

Osage County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk's administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to up...

Chairman of the Board of County Commissioners: The lack of cooperation and oversight during the prior County Clerk's administration left significant gaps that required immediate attention. The current leadership has made addressing these gaps a top priority. Together, we are: • meeting monthly to update procedures and build stronger internal controls, • developing and formalizing policies to ensure full compliance with federal grant requirements, • and improving communication between offices to ensure federal reporting is accurate and timely. Our collective commitment is to put permanent measures in place to prevent these issues from recurring and to uphold the highest level of compliance for all federal programs. County Clerk: I was not the County Clerk in office at this time. The County will comply with all aspects of grant reporting and requirements. The Officials will work together to put policies and procedures in place to ensure more accurate reporting. County Treasurer: The County Officers will work on better communication to more accurately report the SEFA funds.

View Audit 384731

Finding 1171704 (2024-011)

Material Weakness 2024

Osage County

OK

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior County Clerk's administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of...

Chairman of the Board of County Commissioners: These findings trace back to gaps under the prior County Clerk's administration and her lack of cooperation with the Board of County Commissioners, but our focus is on fixing the problems, not dwelling on them. Under the current leadership, the Board of County Commissioners, the new County Clerk and the other elected officials have made addressing these control weaknesses a priority. Together, we are: • strengthening county-wide policies and procedures to meet federal compliance requirements • improving communication and oversight to ensure accurate and timely federal reporting • and establishing clear standards and training for all reporting officers to prevent inaccurate or untimely reporting. Our collective goal is to build a stronger, more accountable system that ensures federal programs are managed with the highest level of integrity. County Clerk: I was not the County Clerk in office at this time. Ensure that the County has standards in place that will deter inaccurate and untimely reporting. In addition, those reporting have the knowledge and understanding to properly report. County Treasurer: The County Officers will work on better communication to more accurately report the Schedule of Expenditures of Federal Awards (SEFA) funds.

View Audit 384731

Finding 1171693 (2024-101)

Material Weakness 2024

City of Parker, Florida

FL

Special Tests & Provisions Subrecipient Monitoring Cash Management § 200.303

City of Parker Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Financial Statement Finding Number: 2024-101: Reimbursement Requests were Not Formally Approved by the City Prior to Submission Planned Corrective Action: The City will update its procedures to require do...

City of Parker Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Financial Statement Finding Number: 2024-101: Reimbursement Requests were Not Formally Approved by the City Prior to Submission Planned Corrective Action: The City will update its procedures to require documented City review and approval of all reimbursement requests prior to submission to a grantor. The City will also clarify responsibilities with the consultant to ensure submission and acknowledgment are independently performed and appropriately documented. Anticipated Completion Date: 09/30/2026 Responsible Contact Person: Kimberly Dalton, Bookkeeper

View Audit 384721

Finding 1171402 (2024-002)

Material Weakness 2024

Center for Independence of Individuals with Disabilities

CA

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Immediate Control Reinforcement and Staff Training - The Executive Director and the Program Manager have already started identifying specific areas of each contract and grant for federal awards. The Executive Director will call a meeting between all managers to go over each contract and grants toget...

Immediate Control Reinforcement and Staff Training - The Executive Director and the Program Manager have already started identifying specific areas of each contract and grant for federal awards. The Executive Director will call a meeting between all managers to go over each contract and grants together with information that has already been reviewed. It will be important to observe specific instances when controls were created, and documentation was not accurate. Staff will be trained regarding the agency budget, and each role and responsibility of their program to better understand how their service delivery affects organizational funding. Monthly monitoring of grant funding from all managers will be important for transparency and prudent decision making. All managers will receive frequent training to keep up with any changes or new processes that will impact federal funding. Monitoring and Periodic Internal Auditing - The Executive Director, Program Manager, and Finance manager will meet every month before the Finance Committee meeting to go over the progression of spending. The Executive Director and Finance Manager will keep record of all information that will be helpful for the next audit regarding federal grants. Written corrective action plans will be created for each area of noncompliance. Finance Manager will be responsible for maintaining accurate budget updates and will inform Executive Director of any updates and changes as soon as they happen to ensure full transparency and preparation. Failure to do so will result in disciplinary consequences. All information will be presented to the Board of Directors whether at the monthly Board meeting or at the request for a special meeting. Documentation and Formalization - The Executive Director will meet with the Finance Manager to understand what process is used for quality assurance and documentation the finance staff uses. Any improvements necessary will be implemented as soon as possible after evaluating all processes. An evaluation of the software used for tracking all grant funding will be done and any quality assurance improvements will be implemented as soon as possible. Federal grants compliance adherence will be included in performance reviews and documented.

View Audit 384680

Finding 1171102 (2024-002)

Material Weakness 2024

CITY OF ROSE CITY, TEXAS

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

The City of Rose City, Texas’s Council has reviewed the findings indicated as 2024-001 and 2024-002 and agree with the findings. The Council adopted controls to ensure that the City will comply in all material respects with its reporting requirements as per the Texas Local Government Code and the Un...

The City of Rose City, Texas’s Council has reviewed the findings indicated as 2024-001 and 2024-002 and agree with the findings. The Council adopted controls to ensure that the City will comply in all material respects with its reporting requirements as per the Texas Local Government Code and the Uniform Guidance 2 CFR 200. In addition, the Council has further involved the outside independent accounting firm to assist the City in its accounting and monitoring activities.

View Audit 384497

Finding 1170947 (2024-001)

Material Weakness 2024

California Coverage and Health Initiatives

CA

Subrecipient Monitoring Allowable Costs / Cost Principles § 200.332

FINDING: 2024-001 Subrecipient Monitoring Name of Contract Person: Alexis Heaton, Executive Director Recommendation: It is recommended that the Organization maintain copies of all monitoring records and results of the site visits, to ensure all required subrecipient monitoring activities are perform...

FINDING: 2024-001 Subrecipient Monitoring Name of Contract Person: Alexis Heaton, Executive Director Recommendation: It is recommended that the Organization maintain copies of all monitoring records and results of the site visits, to ensure all required subrecipient monitoring activities are performed and properly documented in accordance with Uniform Guidance. Corrective Action Plan: The executive director will implement the recommendation. Proposed Completion Date: Immediately

View Audit 384272

Finding 1170944 (2024-002)

Material Weakness 2024

Gallia-Jackson-Meigs Board of Adamh

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.329

The issue has been corrected and reporting will be accurate for 2025.

View Audit 384261

Corrective Action Plans

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