Corrective Action Plans

Finding 1235124 (2025-061)

Material Weakness 2025

State of Montana

MT

Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.332 § 200.403

Inadequate Supporting Documentation - SPED - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented more stringent ...

Inadequate Supporting Documentation - SPED - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented more stringent criteria for cash requests from schools in late 2024, and those requirements have been in place since that time. Although there has been considerable pushback from local education agencies due to the added burden, the Office has remained firm on the information required. Cash requests are audited quarterly by the Internal Control Auditor against submitted budget documents, and any issues identified are addressed. These criteria are fully implemented, and no further corrective action is necessary beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026

View Audit 411404

Finding 1235057 (2025-109)

Material Weakness 2025

State of Montana

MT

Allowable Costs / Cost Principles Subrecipient Monitoring Period of Performance § 200.303 § 200.430

Inadequate Payroll Certification Controls - R&D - UM - The University of Montana - Missoula will work with Information Technology to confirm that Personnel Activity Report reminder emails are sent on the correct schedule and to the appropriate individuals, including the Office of Sponsored Programs....

Inadequate Payroll Certification Controls - R&D - UM - The University of Montana - Missoula will work with Information Technology to confirm that Personnel Activity Report reminder emails are sent on the correct schedule and to the appropriate individuals, including the Office of Sponsored Programs. The University will provide Personnel Activity Report certification training to the campus and will conduct targeted outreach for departments with outstanding records. After the current cleanup effort is completed, Grants and Contracts Officers will review outstanding Personnel Activity Reports quarterly and follow up as needed to promote timely certification. Responsible Party - Nicole Thompson, Director, Office of Sponsored Programs, University of Montana - Missoula Target Implementation Date - 2/28/2027

View Audit 411404

Finding 1230287 (2025-098)

Material Weakness 2025

State of Montana

MT

Subrecipient Monitoring § 200.303

Noncompliant FFATA Reports - Medicaid - DPHHS - The Montana Department of Public Health and Human Services agrees that internal control deficiencies existed in its Federal Funding Accountability and Transparency Act (FFATA) subaward reporting processes during fiscal years 2024 and 2025, and that ins...

Noncompliant FFATA Reports - Medicaid - DPHHS - The Montana Department of Public Health and Human Services agrees that internal control deficiencies existed in its Federal Funding Accountability and Transparency Act (FFATA) subaward reporting processes during fiscal years 2024 and 2025, and that instances of noncompliance occurred. The department has implemented additional internal controls and has corrected the Medicaid FFATA reports. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 7/1/2025

View Audit 411404

Finding 1230267 (2025-018)

Material Weakness 2025

State of Montana

MT

Allowable Costs / Cost Principles HUD Housing Programs Special Tests & Provisions § 200.303

Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer...

Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/19/2026

View Audit 411404

Finding 1230227 (2025-003)

Material Weakness 2025

State of Montana

MT

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Noncompliant FFATA Reports - Nutrition - OPI - The Montana Office of Public Instruction does not concur with the portions of the finding related to historical reporting issues that were fully resolved in the prior audit, including the deletion of historical reports and resubmission of final versions...

Noncompliant FFATA Reports - Nutrition - OPI - The Montana Office of Public Instruction does not concur with the portions of the finding related to historical reporting issues that were fully resolved in the prior audit, including the deletion of historical reports and resubmission of final versions. Earlier discrepancies resulted from concurrent reports within the federal reporting system, which caused amounts to duplicate. Federal partners verbally confirmed the system correction, and SAM.gov was updated at the beginning of fiscal year 2026. These issues were attributable to federal system functionality rather than to the Montana Office of Public Instruction, and reporting was completed as directed. The Office concurs with the portion of the finding involving discrepancies associated with prior‑period adjustments. After awards were liquidated and closed, the Office submitted final reports using complete expenditure data. Subsequent adjustments created differences between the Office’s internal records and federal reporting. For ALN 10.582, the Office concurs with the finding but does not agree that the Office is responsible. SAM.gov did not recognize the Federal Award Identification Number, preventing submission of required reports. This issue was later identified as a broader system problem affecting agencies nationwide. To address the recommendation, the Office will update internal FFATA guidance to ensure continued compliance with federal requirements. Documentation will be retained, and reconciliations will verify values reported in both USAspending and SAM.gov. These actions strengthen internal controls and support timely, accurate reporting. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026

View Audit 411404

Finding 1230201 (2025-082)

Material Weakness 2025

State of Montana

MT

Subrecipient Monitoring Eligibility Material Weakness § 200.332

Inadequate Subrecipient Communications - CCDF - DPHHS - The Montana Department of Public Health and Human Services developed a new contract template that includes all required elements and implemented it for state fiscal year 2025 subawards. The Department is following its updated processes. Respons...

Inadequate Subrecipient Communications - CCDF - DPHHS - The Montana Department of Public Health and Human Services developed a new contract template that includes all required elements and implemented it for state fiscal year 2025 subawards. The Department is following its updated processes. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 7/1/2024

View Audit 411404

Finding 1230199 (2025-080)

Material Weakness 2025

State of Montana

MT

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

Inadequate Monthly Subrecipient Case File Reviews - CCDF - DPHHS - The Montana Department of Public Health and Human Services will further strengthen compliance by enhancing its internal control framework. The Department will refine supervisory review protocols, formalize documentation requirements,...

Inadequate Monthly Subrecipient Case File Reviews - CCDF - DPHHS - The Montana Department of Public Health and Human Services will further strengthen compliance by enhancing its internal control framework. The Department will refine supervisory review protocols, formalize documentation requirements, and improve monitoring procedures to ensure full alignment with State Plan objectives. The department will also review its State Plan and submit an amendment if necessary. These improvements will ensure continued compliance with State Plan requirements. The Department anticipates full implementation of these strengthened processes in early 2027. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 3/26/2027

View Audit 411404

Finding 1230198 (2025-079)

Material Weakness 2025

State of Montana

MT

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

Noncompliant FFATA Reports - CCDF - DPHHS - The Montana Department of Public Health and Human Services partially concurs. The department agrees that internal control deficiencies existed in its subaward reporting processes under the Federal Funding Accountability and Transparency Act (FFATA) during ...

Noncompliant FFATA Reports - CCDF - DPHHS - The Montana Department of Public Health and Human Services partially concurs. The department agrees that internal control deficiencies existed in its subaward reporting processes under the Federal Funding Accountability and Transparency Act (FFATA) during fiscal years 2024 and 2025, and that instances of noncompliance occurred. The department does not concur with the quantified extent of the exceptions, including report counts and reporting figures. The department has been unable to replicate the amounts noted and did not receive sufficient detail, as outlined in 2 CFR 200.516(b), to fully understand the specific errors identified. In response to a prior audit recommendation, the department implemented corrective actions to strengthen its internal controls and review processes. These actions included enhanced oversight and the identification and correction of duplicate and inaccurate records. Many of these duplication issues originated from data quality challenges within the former federal reporting system. When the federal reporting system transitioned to the System for Award Management in state fiscal year 2026, many of those data quality concerns were eliminated. The department corrected most of the duplicated and inaccurate records that migrated from the former system to the new one. The department also enhanced its internal controls and revised its policies and procedures for reporting under FFATA. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 7/23/2025

View Audit 411404

Finding 1230160 (2025-007)

Material Weakness 2025

CITY OF INDIAN HARBOUR BEACH

FL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supe...

Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supervisory reviews to ensure all required reports are submitted accurately and timely. Management Response: Management concurs with the recommendation. The Management Analyst will ensure accurate and timely grant reporting. Anticipated Completion Date: September 30, 2026 Responsible Party: GIna Sherman, Management Analyst

View Audit 411372

Finding 1230156 (2025-001)

Material Weakness 2025

Pierce County

WA

Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pierce County January 1, 2025 through December 31, 2025 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CF...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pierce County January 1, 2025 through December 31, 2025 This schedule presents the corrective action the County is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The County did not have adequate internal controls for ensuring compliance with federal subrecipient monitoring requirements. Name, address, and telephone of County contact person: Jackie Ota 1501 Market Street, Suite 102 Tacoma, WA 98402 (253) 798-7231 Corrective action the auditee plans to take in response to the finding: Internal controls have been strengthened to ensure compliance with federal program requirements. Anticipated date to complete the corrective action: 09/09/2026

View Audit 411362

Finding 1230155 (2025-001)

Material Weakness 2025

Partnership to End Addiction

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

Management concurs with the finding above and recognizes the importance of maintaining compliance with federal award requirements. To address the matter, management will implement the following corrective actions: Update procurement policies and procedures to properly document suspension and debarme...

Management concurs with the finding above and recognizes the importance of maintaining compliance with federal award requirements. To address the matter, management will implement the following corrective actions: Update procurement policies and procedures to properly document suspension and debarment verification through SAM.gov for all applicable vendors and contracts receiving federal funds. If vendors or contractors are not verifiable through SAM.gov, additional procedures will be performed to ensure vendors and contractors are not suspended or debarred. Implement a standardized checklist to ensure all compliance requirements are met Management will perform semi-annual monitoring of federal award transactions and compliance requirements throughout the year Management believes these actions will adequately address the condition noted and reduce the likelihood of recurrence. The Chief Financial Officer is responsible for implementing and monitoring these corrective actions, which are expected to be fully implemented by December 31, 2026

View Audit 411360

Finding 1230060 (2025-002)

Material Weakness 2025

City of Cedarburg

WI

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214

City Response and Corrective Action Plan: Management agrees with the recommendation. Moving forward the City will check vendors in SAM.gov before awarding contracts and will recheck them at least once a year for multi year agreements. Each check will be recorded in a central log, and supporting docu...

City Response and Corrective Action Plan: Management agrees with the recommendation. Moving forward the City will check vendors in SAM.gov before awarding contracts and will recheck them at least once a year for multi year agreements. Each check will be recorded in a central log, and supporting documentation will be kept in our contract and grant files. When needed, the City will collect a vendor certification at the time of award and review compliance annually. The City expects full implementation of these procedures within 60 days, with ongoing monitoring after that.

View Audit 411346

Finding 1230059 (2025-003)

Material Weakness 2025

Maine Sate Housing Authority

ME

Subrecipient Monitoring Reporting

2025-003: Reporting – Temporary Assistance for Needy Families Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2025 the Program Delivery Report,...

2025-003: Reporting – Temporary Assistance for Needy Families Name of Contact Person(s): Bobbie Crooker, Director of Energy and Housing Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees that for 2025 the Program Delivery Report, the Program Projections Report, and many of the Monthly Household reports did not have evidence of submission and that the Closeout Report was not filed timely. This issue occurred due to staff turnover within the LIHEAP Team, within the Fiscal Team, and within the EHS Department overall, as well as due to an insufficient monitoring process regarding reporting requirements. The State of Maine DHHS verbally informed MaineHousing that all 2025 reporting requirements have been satisfied. EHS is in the process of developing and implementing the use of an up-to-date report tracking spreadsheet for the Department. As part of the training for newly onboarded staff, such as the new department Director, the newly hired Quality Control Specialist, and the newly hired Fiscal Compliance Coordinator, EHS has also identified who is responsible for maintaining the tracking spreadsheet, identified who is responsible for the information contained in specific reports, identified who is responsible for submitting each report, and identified who is responsible for updating the department calendar with reminders for report due dates. This spreadsheet will help ensure that all reports for all programs are submitted accurately and in a timely manner in accordance with state guidelines for report submission. Additionally, EHS walked through the process and what is required with a representative from Maine DHHS. For TANF, this process and tracking has been fully implemented. This program was administered as part of a subrecipient agreement with the Maine Department of Health and Human Services (DHHS). Due to structural and fiscal changes at DHHS, MaineHousing concluded its administration of these TANF funds effective July 1, 2026. Proposed Completion Date: Completed in fall of 2025

View Audit 411338

Finding 1230058 (2025-002)

Material Weakness 2025

Maine Sate Housing Authority

ME

Eligibility Subrecipient Monitoring § 200.516

Finding 2025-002: Eligibility – Temporary Assistance for Needy Families Name of Contact Person: Bobbie Crooker, Director of Energy and Housing Services Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees with the finding. The elig...

Finding 2025-002: Eligibility – Temporary Assistance for Needy Families Name of Contact Person: Bobbie Crooker, Director of Energy and Housing Services Management’s Views and Corrective Action Plan: The Department of Energy and Housing Services (EHS) at MaineHousing agrees with the finding. The eligibility determination error occurred because the applicant initially presented a qualifying dependent child that met program requirements. However, the applicant subsequently failed to provide the required verification documentation. Although the applicant should have been deemed ineligible due to noncompliance, the system did not update accordingly to adjust the benefit level. The system has since been corrected to address this issue. Application intake and approval are performed by Community Action Agencies (CAAs) on behalf of MaineHousing. To provide greater assurance that CAAs accurately determine and document participant eligibility, MaineHousing has strengthened its oversight and monitoring procedures. As part of this corrective action, MaineHousing enhanced its monitoring procedures to include additional supervisory review of CAA applications and eligibility determinations. These procedures supplement the annual required risk monitoring performed for each CAA and better enable MaineHousing to identify and address determination errors or related control weaknesses in a timely manner. EHS has reviewed the circumstances surrounding the specific case identified and has determined that it appears that the known questioned costs did not exceed reportable federal thresholds and no further recovery action is necessary. This program was administered as part of a subrecipient agreement with the Maine Department of Health and Human Services (DHHS). Due to structural and fiscal changes at DHHS, MaineHousing concluded its administration of these TANF funds effective July 1, 2026. Proposed Completion Date: Completed

View Audit 411338

Finding 1230057 (2025-001)

Material Weakness 2025

Maine Sate Housing Authority

ME

Reporting Subrecipient Monitoring HUD Housing Programs

Finding 2025-001: Reporting – Community Development Block Grant/State’s Program and Non- Entitlement Grants in Hawaii Name of Contact Person: Ashley Carson, Chief Counsel Management’s Views and Corrective Action Plan: The Legal & Compliance Department is responsible for the submission of the Annual ...

Finding 2025-001: Reporting – Community Development Block Grant/State’s Program and Non- Entitlement Grants in Hawaii Name of Contact Person: Ashley Carson, Chief Counsel Management’s Views and Corrective Action Plan: The Legal & Compliance Department is responsible for the submission of the Annual Performance Report for the Recovery Housing Program and agree with the finding. For 2025, MaineHousing was experiencing an error in HUD’s Disaster Recovery Grant Reporting (DRGR) system with submission of the report and reached out to HUD for assistance. HUD was non-responsive to the first two requests for assistance, and a third request was not made until after the report filing deadline. HUD responded to the third request and assisted by providing technical assistance which allowed the report to be submitted. The report was not filed in a timely manner due to the DRGR system errors and the elapsed time between follow-ups with HUD. As system errors for DRGR are a common issue, the following corrective action will ensure that MaineHousing is proactive in the submission of Annual Performance Report for Recovery Housing. The Annual Performance Report for the Recovery Housing Program is due on October 30th. No later than September 15th each year, MaineHousing will attempt to verify any issues with the DRGR system ahead of the reporting deadline and immediately reach out to HUD for technical assistance with any issues found. MaineHousing will gather the information for the Recovery Housing Annual Performance Report at least 45 days ahead of the October 30th deadline (if available) and attempt submission of that report no later than October 5th. If errors occur in DRGR in submitting the report, MaineHousing will immediately contact HUD and continue to follow up weekly until the issue is resolved, attempting other modes of contact if HUD is unresponsive. If the report cannot be submitted in a timely manner, MaineHousing will request that HUD confirm in writing that late submission is acceptable given the circumstances. Proposed Completion Date: Completed

View Audit 411338

Finding 1230045 (2025-002)

Material Weakness 2025

Boys & Girls Club of Truckee Meadows

NV

Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management

Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly ...

Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly request for reimbursement and supporting documentation, including payroll and nonpayroll costs allocated to the CACFP to verify that costs are appropriately allocated to the program and are allowable under the applicable federal requirements. Evidence of the review and approval will be documented and retained with the monthly reimbursement documentation. Anticipated Completion Date: September 2026 Personnel Responsible for Corrective Action: Alison Elder, CFO

View Audit 411318

Finding 1230018 (2025-001)

Material Weakness 2025

Trumbull County

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

The County will enhance its internal controls over reporting and review federal guidance for reporting under the Coronavirus State and Local Fiscal Recovery Funds.

View Audit 411256

Finding 1230006 (2025-009)

Material Weakness 2025

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

Finding 2025-009: Noncompliance – Special Tests and Provisions Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written procedures and a compliance calendar addressing waiting-list administration, annual utility allowance reviews, an...

Finding 2025-009: Noncompliance – Special Tests and Provisions Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will establish written procedures and a compliance calendar addressing waiting-list administration, annual utility allowance reviews, and required inspection quality-control reviews. The Agency will take the following actions: Waiting-List Administration • Review existing waiting-list records and procedures. • Maintain documentation supporting applications, preferences, applicant selections, withdrawals, removals, updates, and offers of assistance. • Ensure applicants are selected in accordance with the Administrative Plan and documented waiting-list order. • Restrict and monitor access to waiting-list records. • Periodically reconcile system-generated waiting-list reports to supporting documentation. • Conduct and document periodic waiting-list purges in accordance with the Administrative Plan. Utility Allowances • Complete and document an annual review of the Voucher program’s utility allowance schedules. • Retain utility rates, consumption information, calculations, conclusions, and supporting documentation. • Present revisions to the Board for approval when an adjustment is warranted. • Document the review even when no change to the utility allowance schedule is required. Inspection Quality Control • Establish procedures for selecting and completing the required number of quality-control inspections. • Ensure the quality-control sample is selected in accordance with applicable HUD requirements. • Use a qualified individual other than the original inspector to perform the quality-control review. • Document the units reviewed, deficiencies identified, comparison to the original inspection, and corrective action taken. • Apply the HUD inspection standard in effect for the Voucher program at the time of the inspection. • Use quality-control results to identify training needs and improve inspection consistency. Management will review compliance with these requirements periodically and report the results and any unresolved deficiencies to the Board of Commissioners. Estimated Completion Date: Written procedures and the compliance calendar will be implemented by October 31, 2026. The outstanding utility allowance review and initial inspection quality-control review will be completed by December 31, 2026, with annual and periodic monitoring thereafter. Responsible Parties: Executive Director, Housing Choice Voucher program staff, designated inspection personnel, and Board of Commissioners.

View Audit 411231

Finding 1230005 (2025-008)

Material Weakness 2025

Area Xv Multi-County Housing Agency

IA

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Finding 2025-008: Material Weakness in Internal Control Over Compliance – Housing Choice Voucher Program Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will develop and implement a comprehensive system of written internal controls and compliance ...

Finding 2025-008: Material Weakness in Internal Control Over Compliance – Housing Choice Voucher Program Agreement or Disagreement: The Agency agrees with the finding. Planned Corrective Action: The Agency will develop and implement a comprehensive system of written internal controls and compliance procedures for the Housing Choice Voucher Program. The Agency will also: • Develop standardized tenant-file checklists covering eligibility, income, assets, deductions, citizenship or eligible immigration status, Social Security numbers, EIV documentation, rent reasonableness, inspections, leases, HAP contracts, annual and interim reexaminations, portability, and other applicable requirements. • Require the checklist to be completed and maintained in each participant file. • Establish and document supervisory or quality-control reviews of an appropriate sample of applicant and participant files. • Correct deficiencies identified during supervisory reviews and document the corrective action taken. • Update the Administrative Plan to incorporate applicable HOTMA provisions and current HUD guidance. • Establish procedures for reviewing HUD notices, regulations, handbooks, and other program guidance. • Provide regular training to employees responsible for administering the Voucher program. • Clearly assign program responsibilities and develop written procedures to reduce dependence on the knowledge of individual employees. • Maintain a compliance calendar for recurring program responsibilities and reporting deadlines. • Provide the Board with periodic reports regarding compliance reviews, deficiencies identified, and corrective actions completed. Estimated Completion Date: Checklists and supervisory-review procedures will be implemented by October 31, 2026. Written procedures, policy updates, and initial staff training will be completed by December 31, 2026, with ongoing monitoring thereafter. Responsible Parties: Executive Director, Housing Choice Voucher program staff, designated supervisory staff, and Board of Commissioners.

View Audit 411231

Finding 1230004 (2025-006)

Material Weakness 2025

Papa Ola Lokahi

HI

Cash Management Subrecipient Monitoring Internal Control / Segregation of Duties § 200.305

Material Weakness Finding No. 2025-006: Cash Management Views of Responsible Officials and Planned Corrective Action The Organization acknowledges the importance of compliance with 2 CFR §200.305, rules for federal payments; and understood and concurred with the prior year finding (2024-006) and cur...

Material Weakness Finding No. 2025-006: Cash Management Views of Responsible Officials and Planned Corrective Action The Organization acknowledges the importance of compliance with 2 CFR §200.305, rules for federal payments; and understood and concurred with the prior year finding (2024-006) and current year renumbered recommendation (2025-006). A. U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Federal Assistance Listing Number 93.243. The Organization received this award from the HHS, Substance Abuse and Mental Health Services Administration (SAMHSA), via the State of Hawaii, Department of Health (DOH). In other words, SAMHSA awarded federal dollars to the DOH, who then sub-awarded federal dollars to the Organization. The Organization further sub-awarded to eligible community-based organizations (CBOs), for the purpose of SAMHSA emergency response grants (SERG), as a result of the impacts of the Lahaina wildfires in August 2023. Payments from the DOH, is based on the Organization’s meeting the billing parameters as established by the DOH at the time of contracting. Actual billing by the Organization to the DOH, includes the aggregation of eligible expenditures incurred by sub-recipient CBOs, that are subject to reimbursement from the Organization via the DOH reimbursement. Sub-recipient CBO invoices are reviewed and validated by the Organization’s program staff prior to submission for the Organization’s aggregation and invoicing to DOH. 1. The Organization notes the following process in place as of the June 30, 2025 fiscal year end: Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls includes the review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds. This monthly process and review controls functioned to mitigate any internal control non-compliance. 2. The Organization also notes the following processes implemented after the June 30, 2025 fiscal year end: Internal Control Environment Policy – July 2025, Updated August 2026. Established and updated the following policies: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; and Implementation of Health Resources & Services Administration (HRSA) Related Policies, including cash management processes and procedures. Effective September 2026, the Organization will implement an internal control review of the federal funds to ensure compliance with 2 CFR §200.305 for Federal Assistance Listing Number 93.243. B. U.S. Department of Health and Human Services (HHS) Health Care for Native Hawaiians Federal Assistance Listing Number 93.932. This federal award is referred to as either Public Health Services (PHS) or the Native Hawaiian Healthcare Improvement Act (Act) federal dollars. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: 1. System, Process & Review Controls In Practice. a. System Controls. Continued to operate in an environment in which system, process & review controls of the United States Department of Health and Human Services (HHS) are practiced in processing cash (draw) transactions in both the Electronic Handbook (EHB) and Payment Management System (PMS) systems, operated by HHS. Only the director of administrative operations and the CEO have system access to the EHB and PMS systems. b. Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls includes the review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds, and Native Hawaiian Health Program (Fund 007V), and Native Hawaiian Health Scholarship Program (Fund 017V). This monthly process and review controls functioned to mitigate any internal control non-compliance. c. HHS Drawdown Restriction. The Organization remained on HHS imposed drawdown restriction as of June 30, 2024 and June 30, 2025. The restriction was removed by HHS in July 2026. 2. The Organization also notes the following processes implemented after the June 30, 2025 fiscal year end: a. Internal Control Environment Policy – July 2025, Updated August 2026. Implemented and updated the following policies: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; and Implementation of Health Resources & Services Administration (HRSA) Related Policies, including cash management processes and procedures. b. Additional Process & Review Controls – EHB & PMS. Effective March 1, 2026, the Organization implemented, federal draws, process and review of internal controls implemented, via the chief of staff’s review of the director of administrative operations cash management analyses, federal grant receivable composition, reconciliation and related federal grant revenue computations, prior to any director of administrative operations and chief executive officer action in EHB and PMS, respectively. Finding No. 2025-006: Cash Management Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D., Chief of Staff.

View Audit 411216

Finding 1230003 (2025-005)

Material Weakness 2025

Papa Ola Lokahi

HI

Subrecipient Monitoring

Material Weakness Finding No. 2025-005: Document Retention Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Feder...

Material Weakness Finding No. 2025-005: Document Retention Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. The Organization further refers to the corrective action plan of Finding No. 2025-002: Subrecipient Monitoring, which describes the Organization’s implemented changes re: Subrecipient Monitoring and Management, Retroactive Subrecipient Portfolio Risk Assessment and Correction(s), and Subrecipient Policies and Procedures. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Contractor Performance Collection and Substantiation – November 2024. Incorporated specific review procedures to ensure the timely collection and substantiation of contractor performance deliverables (e.g., products, goods, services, activities, reports), consistent with the terms and conditions of the contract. B. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. C. Discussed with respective program director(s), the implementation of initiation, consideration, decision, documentation and monitoring phased activities. D. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. E. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date. Finding No. 2025-005: Document Retention Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D. Chief of Staff.

View Audit 411216

Finding 1230000 (2025-002)

Material Weakness 2025

Papa Ola Lokahi

HI

Subrecipient Monitoring § 200.331 § 200.332

Material Weakness Finding No. 2025-002: Subrecipient Monitoring Views of Responsible Officials and Planned Corrective Action The Organization acknowledges 2 CFR§ 200.331 and 2 CFR §200.332 of the Uniform Guidance, and its subrecipient monitoring and management provisions emphasizing accountability a...

Material Weakness Finding No. 2025-002: Subrecipient Monitoring Views of Responsible Officials and Planned Corrective Action The Organization acknowledges 2 CFR§ 200.331 and 2 CFR §200.332 of the Uniform Guidance, and its subrecipient monitoring and management provisions emphasizing accountability and compliance in managing federal funds and subrecipients. The Organization concurs with the prior year (2024-002) and current year renumbered recommendation (2025-002) and highlights its ongoing progressive and corrective implementation of policy and process actions. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: A. Subrecipient Monitoring and Management. Implemented internal process changes, effective November 1, 2024, specifically, prospectively, and consistently the: 1. Use of a checklist, to comprehensively assess risk of determining subrecipient or contractor classification, before entering into any subrecipient agreement; 2. Provision of identification details such as CFDA number, amount of federal funds obligated, and the award period for determined subrecipient awards; 3. Submission of programmatic and financial reports as specified in the subrecipient agreement; 4. Review of a single audit in accordance with 2 CFR Part 200, Subpart F for subrecipients that expend $750,000 or more in federal funds during a fiscal year, if applicable; and 5. Review of their audit report(s) and addressing any finding(s) related to their federal award(s), including the related appropriate corrective actions, when applicable. B. Retroactive Subrecipient Portfolio Risk Assessment and Correction(s). Performed a risk assessment of the existing subrecipient portfolio to identify risks, for the audit periods July 1, 2022 – June 30, 2023, and July 1, 2023 – June 30, 2024. The objective of this risk assessment was to identify, evaluate, and prioritize risks that could adversely impact the Organization’s ability to achieve its strategic, operational, compliance and quality assurance goals. The completion of the Organization’s portfolio risk assessment resulted in correction of identified non-compliant subrecipient agreement(s). C. Subrecipient Policies and Procedures. Updated, by December 31, 2024, the implemented financial policies and procedures aligned to the subrecipient monitoring and management provision of 2 CFR §200.331 and 2 CFR §200.332 of the Uniform Guidance, including checklists, flowcharts, samples, data sheets, data sharing agreements, etc. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work: A. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. B. Discussed with respective program director(s), the implementation of initiation, consideration, decision, documentation and monitoring phased activities. C. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. D. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date. Finding No. 2025-002: Subrecipient Monitoring Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations and Sylvia Hussey, Ed.D., Chief of Staff.

View Audit 411216

Finding 1229922 (2025-001)

Material Weakness 2025

Northern Oswego County Health Services, Inc. Dba Connextcare

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review, it was determined that the configuration of the Sliding Fee Discount Program within our Practice Management System had been set up ...

Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review, it was determined that the configuration of the Sliding Fee Discount Program within our Practice Management System had been set up incorrectly. Specifically, the "Slide After Insurance Method" setting was configured as CHGAMT rather than BALANCE. The Sliding Fee Maintenance settings were corrected in the system on May 27, 2026, to ensure the Sliding Fee Discount Program is applied appropriately following insurance adjudication. In addition, ConnextCare conducted a comprehensive audit of all 2026 dates of service for patients actively enrolled in the Sliding Fee Discount Program. No additional occurrences of this issue were identified. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 264-0991. Sincerely yours, Tracy Wimmer Sr. VP/Chief Financial Officer

View Audit 411164

Finding 1229921 (2025-002)

Material Weakness 2025

Pickaway County

OH

Subrecipient Monitoring Reporting

We will correct our reporting issues with the next required report.

View Audit 411161

Finding 1229919 (2025-003)

Material Weakness 2025

TOWN OF SAINT MATTHEWS

SC

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318

Finding 2025-003 No Written Conflict of Interest Policy Finding: The Town does not have a written conflict of interest policy as required by 2 CFR § 200.318(c)(1). Corrective Action The Town of St. Matthews concurs with the finding. The Town recognizes the importance of maintaining formally adopted ...

Finding 2025-003 No Written Conflict of Interest Policy Finding: The Town does not have a written conflict of interest policy as required by 2 CFR § 200.318(c)(1). Corrective Action The Town of St. Matthews concurs with the finding. The Town recognizes the importance of maintaining formally adopted written standards of conduct governing actual, potential, and perceived conflicts of interest involving employees and governing body members who participate in the selection, award, or administration of contracts supported by federal funds. To address the finding, the Town will develop a written conflict of interest policy that complies with applicable federal requirements, including 2 CFR § 200.318(c)(1). At a minimum, the policy will: 1. Define actual, potential, and perceived conflicts of interest and prohibited conduct; 2. Identify the employees, officials, and governing body members subject to the policy; 3. Require prompt written disclosure of relevant financial interests and other potential conflicts; 4. Establish procedures for reviewing, documenting, and resolving disclosed conflicts; 5. Require affected individuals to refrain from participating in matters in which a conflict exists; 6. Establish appropriate disciplinary or corrective measures for violations; 7. Require periodic written conflict-of-interest acknowledgments and disclosures; and 8. Address the retention of acknowledgments, disclosures, determinations, and related compliance documentation. The proposed policy will be presented to the Town Council for formal consideration and adoption. Following adoption, the Town will distribute the policy to applicable employees and governing body members and provide appropriate training or written guidance regarding their responsibilities. The Town will retain completed acknowledgments, disclosures, and documentation of any conflict determinations in accordance with its applicable record-retention requirements. Management will periodically review the policy and related procedures to help ensure continued compliance with federal award requirements. Responsible Official Town Administrator Anticipated Completion Date December 31, 2026. Current Status The Town currently does not have a written conflict of interest policy.

View Audit 411157

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