Corrective Action Plans

Finding 1216172 (2022-009)

Material Weakness 2022

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the submission requirement is unclear, the Authority will consult with its federal partner to obtain a determination.

View Audit 402648

Finding 1216171 (2022-008)

Material Weakness 2022

Virgin Islands Port Authority

VI

Questioned Costs Subrecipient Monitoring Reporting § 200.303

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filin...

The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filings and maintains a working spreadsheet of items sent. In addition, Accounting has implemented a tickler system to remind staff to submit financial reports to Engineering or the grantor.

View Audit 402648

Finding 1216167 (2022-006)

Material Weakness 2022

Virgin Islands Port Authority

VI

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

The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.

View Audit 402648

Finding 1214376 (2022-012)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Reporting § 200.302 § 200.327

2022-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as de...

2022-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as defined under policy. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 401032

Finding 1214375 (2022-011)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Cash Management § 200.305

2022-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...

2022-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 401032

Finding 1214370 (2022-006)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Subrecipient Monitoring Material Weakness Internal Control / Segregation of Duties

2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...

2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.

View Audit 401032

Finding 1214365 (2022-001)

Material Weakness 2022

St. Croix Chippewa Housing Authority

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency

2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...

2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.

View Audit 401032

Finding 1214252 (2022-003)

Material Weakness 2022

Urban Partnerships Community Development Corporation

TX

Subrecipient Monitoring Reporting § 200.302 § 200.502 § 200.510

Management agrees with the finding and is in the process of revising internal controls to address SEFA preparation.

View Audit 400976

Finding 1214251 (2022-002)

Material Weakness 2022

Urban Partnerships Community Development Corporation

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management ...

This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management will implement proper policies and procedures to ensure the Organization and Affiliates' activities are properly recognized. In addition, management will reconcile the activities of the Organization and Affiliates quarterly against the financial system and ensure activities are recognized properly at year-end.

View Audit 400976

Finding 1211144 (2022-005)

Material Weakness 2022

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400353

Finding 1210523 (2022-008)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Subrecipient Monitoring Eligibility Questioned Costs

REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants t...

REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210508 (2022-007)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...

REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745

View Audit 399930

Finding 1210493 (2022-005)

Material Weakness 2022

The Salvation Army Golden State Division

CA

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

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...

REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1210478 (2022-004)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Cash Management Questioned Costs Subrecipient Monitoring § 200.3 § 200.305

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US T...

REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1210463 (2022-003)

Material Weakness 2022

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Cash Management

REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, ...

REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, it does state that the determination of when an award is expended must be based on when the activity related to the federal award occurs. Uniform Guidance also states for Grants, cost reimbursement contracts, cooperative agreements, and direct appropriation type of contracts, the federal expenditure or expense should be reported when the transaction occurs. Uniform Guidance further states, the auditee should also be able to reconcile amounts presented in the financial statements to related amounts in the schedule of expenditures of federal awards. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division report to the pass-through entity on an accrual basis. Division’s schedule of expenditures of federal awards is presented on the accrual basis of accounting. Of the Sixty (60) files selected for testing: • Five (5) prior year expenditures were included in Division’s current year schedule of expenditures of federal awards. Questioned Costs: Cannot be determined Recommendation: We recommend Division report program expenditures in the year expenditures were accrued. Corrective Action Plan: The Division will report program expenditures in the year expenditures were accrued. Step 1 Action Date: Ongoing Final Implementation Date:h 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

View Audit 399930

Finding 1208190 (2022-005)

Material Weakness 2022

Christian Theological Seminary, Inc.

IN

Student Financial Aid Subrecipient Monitoring Matching / Level of Effort / Earmarking

The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.

View Audit 399050

Finding 1208179 (2022-002)

Material Weakness 2022

County of Aroostook

ME

Subrecipient Monitoring Procurement, Suspension & Debarment § 200.214 § 200.332

CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notificatio...

CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notification of the finding on January 15, 2026, the County developed a formal Subrecipient Monitoring Policy intended to ensure compliance with the requirements of 2 CFR 200.214 and 2 CFR 200.332. The policy establishes procedures for subrecipient versus contractor determination, required subaward agreement elements, Debarment and Suspension verification, risk assessment, ongoing monitoring activities, Single Audit determination and follow-up, and enforcement of corrective actions. The policy is scheduled to be presented for formal adoption at the next available County Commissioner meeting on February 18, 2026. Upon adoption and implementation, these measures are expected to strengthen internal controls over subrecipient monitoring and reduce the risk of future noncompliance with federal award requirements. Anticipated Completion Date: February 18, 2026

View Audit 399031

Finding 1206309 (2022-007)

Material Weakness 2022

Island Health, Inc.

MA

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...

Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.

View Audit 398372

Finding 1182847 (2022-002)

Material Weakness 2022

Prevent Child Abuse Utah

UT

Questioned Costs Subrecipient Monitoring Reporting § 200.512

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.

View Audit 394245

Finding 1181984 (2022-004)

Material Weakness 2022

Community Services Office of Hot Springs and Garland County, Arkansas, Inc.

AR

Subrecipient Monitoring Internal Control / Segregation of Duties Questioned Costs § 200.328 § 200.329

Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a...

Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a process where a staff accountant will prepare the necessary reports and the chief financial officer will review such reports. Alternatively, if the chief financial officer must prepare such reports, the review will be performed by the executive director.

View Audit 393341

Finding 1181964 (2022-102)

Material Weakness 2022

Inter-Tribal Council of Nevada, Inc.

NV

Subrecipient Monitoring Reporting Equipment & Real Property Management § 200.328

Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package f...

Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package for the fiscal year ended September 30, 2022, was not submitted to the Federal Audit Clearinghouse within nine months after ITCN’s year-end. Recommendation: The auditors recommended that ITCN devote the necessary resources to the financial reporting process and establish a system of monitoring for the filing of all required reporting and that the executive director review the monitoring list on a regular basis consistent with the timing of report filings. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN has created a federal reporting compliance calendar with automated reminders. Fiscal contractors continue to support timely submission of required reports. MIP/Microix will allow automated report generation and tracking. The training plan includes modules on reporting compliance and deadline monitoring. Anticipated Completion Date: The calendar was implemented in March 2024, with full automation and staff training to be completed by March 2026.

View Audit 393293

Finding 1175571 (2022-009)

Material Weakness 2022

Dewey County

OK

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.317 § 200.318 § 200.327 § 200.84

The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.

View Audit 389361

Finding 1175569 (2022-007)

Material Weakness 2022

Dewey County

OK

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

The County will include all federal grant discussion in our Officers’ meetings so that all Elected Officials are aware. We will discuss the Control Environment, Risk Assessment, Information and Communication, and Monitoring for all federal grants.

View Audit 389361

Finding 1174932 (2022-017)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors...

Finding 2022-017 Procurement Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Paula Vann, Grants Compliance Officer. Action: Will adhere to the most active Procurement Policy and will check for Debarment for all vendors. Procurement procedures will be updated to clearly define vendor classification and SAM.gov requirements. Anticipated Completion Date: March 2026.

View Audit 388523

Finding 1174926 (2022-013)

Material Weakness 2022

Kickapoo Tribe in Kansas

KS

Subrecipient Monitoring Reporting Questioned Costs § 200.303

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...

Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.

View Audit 388523

Corrective Action Plans

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