Corrective Action Plans

Finding 1154976 (2024-001)

Material Weakness 2024

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 367318

Finding 1154975 (2024-001)

Material Weakness 2024

Vhh - Jg Commons

WA

Cash Management HUD Housing Programs Reporting

Corrective Action: Management made a deposit for a total of $8,582 to cover the underfunded residual receipts. Management will maintain tracking record every year to ensure that the residual receipts account is appropriately funded. The bookkeeper will maintain the record and ensure that deposits ar...

Corrective Action: Management made a deposit for a total of $8,582 to cover the underfunded residual receipts. Management will maintain tracking record every year to ensure that the residual receipts account is appropriately funded. The bookkeeper will maintain the record and ensure that deposits are made as required.

View Audit 367316

Finding 1154973 (2024-010)

Material Weakness 2024

City of Opa Locka

FL

Allowable Costs / Cost Principles Reporting § 200.512

The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP’s are being reviewed with staff for implementation. This activity is ongoing. Responsible Party: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator The ab...

The City has a Grants Administrator on staff that monitors and advises when reports are due to external entities. SOP’s are being reviewed with staff for implementation. This activity is ongoing. Responsible Party: Ms. Niema Gantt, Finance Director, and Ms. Yesly Guillen, Grants Administrator The above corrective action plan is expected to be implemented in the next 12 months.

View Audit 367314

Finding 1154958 (2024-002)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.430 § 200.512

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and...

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154957 (2024-001)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.512

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of ...

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154955 (2024-003)

Material Weakness 2024

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.

View Audit 367288

Finding 1154954 (2024-001)

Material Weakness 2024

Sumter County Board of Education

GA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303 § 200.403 § 200.415

FA 2024-001 Improve Budgetary Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Thro...

FA 2024-001 Improve Budgetary Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425U210012 (Year: 2021) Questioned Costs: $21,615 Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed instances in which expenditures had not been properly approved by the pass- through entity. Corrective Action Plans: Going forward, the Sumter County Schools Program Director will review, sign, and date all purchase orders to signify that the Program Director has verified that the federal program costs have been written and approved in the consolidated application and/or the budget has been amended to include the costs and approved in the consolidated application and the costs are accurately reflected in the general ledger prior to payment. Estimated Completion Date: August 1, 2025 Contact Person: Jannie Carter, Finance Director Telephone: (229)931-8500 Email: janniecarter@sumterschools.org

View Audit 367287 Questioned Costs: $1

Finding 1154953 (2024-003)

Material Weakness 2024

Southwestern Area Health Education Center, Inc.

CT

Procurement, Suspension & Debarment § 200.214 § 200.317 § 200.318 § 200.327

Condition: The Organization did not maintain documented procedures, consistent with the standards identified in 2 CFR 200.317 through 200.327 of the Uniform Guidance, for procurement transactions under a federal award or subaward. The Organization also did not comply with 2 CFR 200.318 (h) and 200.2...

Condition: The Organization did not maintain documented procedures, consistent with the standards identified in 2 CFR 200.317 through 200.327 of the Uniform Guidance, for procurement transactions under a federal award or subaward. The Organization also did not comply with 2 CFR 200.318 (h) and 200.214 of the Uniform Guidance including verifying that vendors for covered transactions are not debarred, suspended, or otherwise excluded from receiving or participating in Federal awards. There were two vendors with covered transactions charged to the major program. The vendors were not debarred, suspended, or otherwise excluded. However, the Organization did not perform and document the required verification. Recommendation: The Organization should draft and maintain documented procedures, consistent with the standards identified in 2 CFR 200.317 through 200.327 of the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: The Organization agrees with the finding and recommendation. The anticipated completion date for the corrective action is October 30, 2025.

View Audit 367273

Finding 1154952 (2024-002)

Material Weakness 2024

Southwestern Area Health Education Center, Inc.

CT

Questioned Costs Cash Management Period of Performance § 200.302 § 200.305

Condition: The Organization’s expenditure reports filed with the grantor for the cost reimbursement-based grant were overstated, and the Organization was overpaid by $182,167, of which $26,730 was received after yearend. The overpayment has not yet been refunded back to the grantor, over a year afte...

Condition: The Organization’s expenditure reports filed with the grantor for the cost reimbursement-based grant were overstated, and the Organization was overpaid by $182,167, of which $26,730 was received after yearend. The overpayment has not yet been refunded back to the grantor, over a year after the performance period of the grant had ended. Recommendation: The Organization should coordinate with the grantor the return of the unspent funds. The Organization should reevaluate its grant expenditure reporting procedures to better mitigate the risk of inaccurate filing and improper reimbursement. Views of Responsible Officials and Planned Corrective Actions: The Organization agrees with the finding and recommendation. The anticipated completion date for the corrective action is October 30, 2025.

View Audit 367273 Questioned Costs: $1

Finding 1154951 (2024-005)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

HUD Housing Programs Period of Performance Significant Deficiency

Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are no...

Finding 2024-005: PERIOD OF PERFORMANCE Description of Finding: Capital Funds identified in the PHA's CFP 5-Year Action Plan to be transferred to operations are obligated by the PHA once the funds have been budgeted and drawn down by the PHA. Capital Funds transferred to operations (BLI 1406) are not considered obligated until the PHA has budgeted and drawn down the funds. To meet this requirement, the funds must be budgeted in line BLI 1406 (Operations) and the PHA must submit the voucher request in LOCCS. (24 CFR Section 905.314(I)). Statement of Concurrence or NonConcurrence: The Authority had obligated capital funds related to operations (BLI 1406) for Capital Fund years 2020 and 2022 prior to the voucher request date for these draws. The Authority had six open capital fund grants during fiscal year 2024 (Capital Fund years 2019-2024). The Authority obligated the BLI 1406 funding for Capital Fund 2020 in March 2024 and Capital Fund 2022 in May 2024. The Authority submitted the voucher requests in February 2025. Corrective Action: Funds in 1406 will be drawn down directly after obligation. Name of Contact Person: Cheryl Thibeault Projected Completion Date: 09/30/2025

View Audit 367267

Finding 1154950 (2024-004)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

Questioned Costs Procurement, Suspension & Debarment § 200.67 § 200.88

Finding 2024-004: PROCUREMENT, SUSPENSION, AND DEBARMENT Description of Finding: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBH...

Finding 2024-004: PROCUREMENT, SUSPENSION, AND DEBARMENT Description of Finding: For any amounts above the Petty Cash ceiling, but not exceeding $250,000 in accordance with revisions to 2CFR 200.67 and 2 CFR 200.88, the NBHA may use small purchase procedures. Under small purchase procedures, the NBHA shall obtain a reasonable number of quotes (preferably three); however, for purchases of less than $10,000, per NDAA Section 806 also known as Micro Purchases, only one quote is required provided the quote is reasonable. Statement of Concurrence or NonConcurrence: Identified 4 instances in which sufficient documentation was not maintained to support the procurement of a vendor. Corrective Action: Three of the vendors have services that will be put out to bid (landscaping, contract repairs and hazardous cleanup). The third service provided is generally of an emergency nature (plumbing) as we have a licensed plumber on staff. NBHA will make sure we have secured verbal quotes for each occurrence before obligating the vendor. Name of Contact Person: Tracy Blackwell Projected Completion Date: 09/30/2025

View Audit 367267 Questioned Costs: $1

Finding 1154949 (2024-003)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

Cash Management HUD Housing Programs Subrecipient Monitoring § 200.305

Finding 2024-003: Cash Management Description of Finding: For recipients and subrecipients other than States, payment methods must minimize the time elapsing between the transfer of funds from the Federal agency or the pass-through entity and the disbursement of funds by the recipient or subrecipien...

Finding 2024-003: Cash Management Description of Finding: For recipients and subrecipients other than States, payment methods must minimize the time elapsing between the transfer of funds from the Federal agency or the pass-through entity and the disbursement of funds by the recipient or subrecipient regardless of whether the payment is made by electronic funds transfer or by other means. (2 CFR 200.305 (b)) Once funds are disbursed, i.e. transferred from LOCCS to the PHA’s bank account, the PHA must pay the applicable bill(s) within 3 business days after the deposit of the funds into the PHA’s bank account. (HUD Capital Fund Guidebook; Section 7.9) Statement of Concurrence or NonConcurrence: A sample of 4 drawdowns of capital funds from ELOCCs during the year identified 1 instance in which the Authority did not process payment to the vendor within 3 business days of receiving the funds. Corrective Action: The Authority processes a weekly check run for all payables. The timing of the receipts from ELOCCs missed the run and the invoice was added to the following weekly run. The authority will better monitor the receipt of funds and if necessary perform an additional check run to disburse the funds to the recipient. Name of Contact Person: Cheryl Thibeault Projected Completion Date: 09/30/2025

View Audit 367267

Finding 1154948 (2024-002)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

Questioned Costs HUD Housing Programs Material Weakness

Finding 2024-002: HOUSING ASSISTANCE PAYMENT Description of Finding: During the term of each assisted lease, and for at least three years thereafter, the PHA must keep: (1) A copy of the executed lease; (2) The HAP contract; and (3) The application from the family. (24 CFR 982.158 (e) The PHA may no...

Finding 2024-002: HOUSING ASSISTANCE PAYMENT Description of Finding: During the term of each assisted lease, and for at least three years thereafter, the PHA must keep: (1) A copy of the executed lease; (2) The HAP contract; and (3) The application from the family. (24 CFR 982.158 (e) The PHA may not pay any housing assistance payment to the owner until the HAP contract has been executed. (24 CFR 982.305 (c)(2)) Statement of Concurrence or NonConcurrence: A sample of 25 participants in the Housing Choice Voucher Program. There were 5 identified instances in which the HAP contract was not properly executed by either the landlord or the PHA. Corrective Action: It was found that the 5 identified instances were completed by staff no longer with the authority. The five have been corrected. Staff have now been trained to perform and review of the contract during any annual or interim certification. All new moves and changes to contracts are given to the manager to ensure utility responsibilities are correctly reflected in the lease, contract, and in the software and that families are correctly credited. The HCV Director will due random review of files to ensure compliance. Name of Contact Person: Maribel Aguliar Projected Completion Date: 09/30/2025

View Audit 367267 Questioned Costs: $1

Finding 1154947 (2024-001)

Material Weakness 2024

Housing Authority of the City of New Britain

CT

HUD Housing Programs Material Weakness Special Tests & Provisions

Finding 2024-001: SPECIAL TESTS AND PROVISIONS – HQS ENFORCEMENT Description of Finding: A sample of 40 failed HQS inspections during the year. In 31 out of the 40 failed HQS inspections, the PHA re-inspection did not occur within 30 days. In 2 of the 40, we were not provided with documentation show...

Finding 2024-001: SPECIAL TESTS AND PROVISIONS – HQS ENFORCEMENT Description of Finding: A sample of 40 failed HQS inspections during the year. In 31 out of the 40 failed HQS inspections, the PHA re-inspection did not occur within 30 days. In 2 of the 40, we were not provided with documentation showing the unit passed HQS. Statement of Concurrence or NonConcurrence: The Authority may have made housing assistance payments to landlords for units that failed to meet housing quality standards or failed to properly abate HAP in cases where HQS deficiencies were not corrected in a timely manner. Corrective Action: An internal inspector was hired in November 2024 which will allow for better follow through and communication as opposed to a contracted inspector. The internal inspector will have full access to the inspection module in Pha Web with timely data entry will ensure that abatements are placed on non-compliant properties. The HCV Director will monitor inspections completed for proper disposition and also run reports on units due in the upcoming month to make sure they are executed and updated in Pha Web. Procedures will be strengthened to ensure that documentation is maintained for all inspections and enforcements. Name of Contact Person: Maribel Aguliar Projected Completion Date: 09/30/2025

View Audit 367267

Finding 1154946 (2024-009)

Material Weakness 2024

Franklin County, Florida

FL

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.403 § 200.405

We agree with the findings and recommendations. This was an isolated incident whereas the payment amount was mistakenly pulled from the wrong line on a contractor’s pay application. This overpayment was missed in the subject fiscal year as the program was still active. Once the overpayment was ident...

We agree with the findings and recommendations. This was an isolated incident whereas the payment amount was mistakenly pulled from the wrong line on a contractor’s pay application. This overpayment was missed in the subject fiscal year as the program was still active. Once the overpayment was identified, the county sought reimbursement from the vendor for the overpayment and has since received the funds. The reimbursement will be included as program revenues in the next audit report. The County will reconcile contract values as each pay application is processed in lieu of awaiting program/project closeout in the future.

View Audit 367258 Questioned Costs: $1

Finding 1154945 (2024-001)

Material Weakness 2024

Palouse Conservation District

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Palouse Conservation District January 1, 2024 through December 31, 2024 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Feder...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Palouse Conservation District January 1, 2024 through December 31, 2024 This schedule presents the corrective action the District 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: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal suspension and debarment requirements.Name, address, and telephone of District contact person: Rachel Magers 1615 NE Eastgate Bldg. H Pullman, WA 99163 (509) 332-4101 ext. 110 Corrective action the auditee plans to take in response to the finding: The Palouse Conservation District appreciates the opportunity to respond to the finding and acknowledges the conclusion of the Washington State Auditor’s Office. While the District is aware of the federal suspension and debarment requirements, there was misunderstanding in retaining the proper documentation of the exclusion records from the U.S. General Services Administration’s System for Award Management. The deficiency in internal controls was identified prior to the end of FY24 and the District has implemented proper document retention to comply with the federal requirement. To further strengthen our internal controls and prevent recurrence, the District is implementing additional measures: 1. Internal Verification Log – A formalized verification log will be incorporated into our procurement process to ensure verification and documentation are completed before contracts are signed and payments are processed. 2. Staff Training and Monitoring – Additional training will be conducted to reinforce compliance procedures, and periodic internal reviews will be performed to ensure adherence to federal requirements. The Palouse Conservation District recognizes the importance of maintaining strong internal controls and ensuring compliance with federal requirements. We appreciate the auditor’s recommendations and are committed to the continual improvement of our processes. Anticipated date to complete the corrective action: October 2025

View Audit 367255

Finding 1154944 (2024-002)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Procurement, Suspension & Debarment § 200.214

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-002 – Procurement and Suspension and Debarment Description of Finding: BCHN did not perform a check at th...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-002 – Procurement and Suspension and Debarment Description of Finding: BCHN did not perform a check at the System for Award Management Exclusions (sam.gov) to verify whether an employee or a vendor had been suspended or debarred before being hired. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN will engage an outside vendor to aid in the review of vendors and employees that are excluded or debarred. The outside vendor will check for exclusion or debarment monthly and provide BCHN with a report indicating that the check was done. The outside vendor will alert BCHN if any vendors or employees are flagged. This will help BCHN to ensure that this check is done timely. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154943 (2024-001)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Reporting Subrecipient Monitoring HUD Housing Programs § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: Th...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-001 – Reporting: Federal Funding Accountability and Transparency Act (“FFATA”) Description of Finding: The FFATA subawards were not submitted timely to the Federal Funding Accountability and Transparency Act Subaward Reporting System (“FSRS”). The review and approval occurred after the FFATA subaward was submitted to the FSRS. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has created a policy regarding the FFATA reporting process. In this process the Electronic Handbook (EHB) is reviewed weekly to ensure that if new awarded funding is released, BCHN is alerted to the need to complete the FFATA report. BCHN has created a spreadsheet to track all the awarded funding and due dates for FFATA reports. Every month, at the board meeting, the spreadsheet is presented to the board with any new awarded funding and when the FFATA report is completed. BCHN has begun a process where the FFATA report is put together by the Finance Manager and reviewed and signed off by the CFO before submitting the report. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154942 (2024-004)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles HUD Housing Programs Period of Performance § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154941 (2024-003)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: There w...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-003 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154926 (2024-002)

Material Weakness 2024

City of Spokane

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Spokane January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 2...

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Spokane January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported 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: 2024-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of City contact person: Skyler Brown, Grants and Contracts Financial Manager W 808 Spokane Falls Blvd Spokane, WA 99201 (509) 625-6294 Corrective action the auditee plans to take in response to the finding: The City currently has a contracting process to verify and document its contractors, consultants and vendors are neither debarred nor suspended. This process adds required certification language to all City agreements to document compliance. While this purchase was reviewed and the compliant status of the providers were verified through the existing cooperative agreement, the City’s process did not capture the needed requirement to verify at the lower tier. This was identified in the prior audit, and due to the timing of this issue and the prior audit finding, the corrections put in place to catch these kinds of purchases going forward had not been put in place yet, and the debarment search on this purchase occurred after the purchase had been made. The City has put into place a requirement that all subawards, purchase agreements and contracts involving federal funds over $25,000 include the required certification even if the contract is derived from “piggy backing” and includes debarment language. Every Contract that receives grant funding goes through the Grants office during the contracting approval process, and this debarment upload is something Grants office is now looking for before approving a contract to move further along the approval process. Anticipated date to complete the corrective action: Currently Active

View Audit 367250

Finding 1154925 (2024-005)

Material Weakness 2024

Sovereign Equity Fund

ND

Subrecipient Monitoring

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #5 – Sovereign Equity Fund – Fisc...

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #5 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: FFATA Reporting - Organization failed to report first-tier subawards in the FSRS system as required under the Federal Funding Accountability and Transparency Act. Corrective Actions: • Designate a responsible party to oversee FFATA compliance. • Update award tracking system to recognize and implement procedures for all first-tier subawards ≥$30,000 for FFATA reporting. • Incorporate FFATA reporting deadlines into grants calendar (due by the end of the month following the award date). • Provide FFATA compliance training and ensure timely access to FSRS.gov. Responsible Party: Executive Director Target Completion Date: Within 14 days; calendar tracking system in use for next subaward Sincerely, Courtney Chavis Executive Director

View Audit 367244

Finding 1154924 (2024-004)

Material Weakness 2024

Sovereign Equity Fund

ND

Subrecipient Monitoring § 200.331 § 200.332

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #4 – Sovereign Equity Fund – Fisc...

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #4 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: Subrecipient Monitoring - Subrecipient agreements lacked required federal clauses and were not monitored according to risk assessments. Corrective Actions: • Develop a subrecipient monitoring policy aligned with 2 CFR §200.331-333. • Standardize agreement templates to include all required clauses for federal award subrecipient agreements (e.g., audit requirements, FFATA, termination provisions). • Implement a subrecipient risk assessment tool to determine monitoring frequency and risk level identification. • Assign staff for annual subrecipient desk reviews or site visits based on risk levels. Responsible Party: Executive Director / Legal & Compliance Team Target Completion Date: Risk assessment and financial monitoring tool in use and agreement templates updated within 45 days. Sincerely, Courtney Chavis Executive Director

View Audit 367244

Finding 1154923 (2024-003)

Material Weakness 2024

Sovereign Equity Fund

ND

Questioned Costs Cash Management Subrecipient Monitoring § 200.305

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fisc...

August 15, 2025 United States Department of Agriculture National Institute of Food and Agriculture Awards Management Division 805 Pennsylvania Ave Kansas City, MO 64105 Attention: Federal Audit Clearinghouse (FAC) Subject: Corrective Action Plan Submission – Finding #3 – Sovereign Equity Fund – Fiscal Year End 12/31/2024 To Whom It May Concern: Funds were drawn down in advance under a reimbursement-based award, potentially violating federal cash management standards (2 CFR §200.305). As referenced and in relation to Finding #2 - Grant funds were drawn in excess of current expenditure needs, which resulted in the Organization being required to return the excess funds to the federal government. 2024-002 – Cash Management, 2 CFR 200.305 (Payment). Corrective Actions: • The Organization has returned the excess funds to the federal government.. • Revise internal procedures to include verification of expenditures for eligible and allowable expenses before initiating a draw request. • Develop a drawdown checklist and require supporting documentation for incurred costs, retain supporting documentation for all drawdowns. • Require Executive Director approval prior to all federal drawdowns. • Conduct training on federal reimbursement protocols for program and finance staff. Responsible Party: Grants Manager / Executive Director Target Completion Date: Policy update within 2 weeks; checklist rollout within 30 days Sincerely, Courtney Chavis Executive Director

View Audit 367244 Questioned Costs: $1

Finding 1154922 (2024-004)

Material Weakness 2024

City of Owatonna

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Th...

Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the City adopt a procurement policy that includes procedures over suspension and debarment. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The City will prepare a policy and have it adopted by the City Council. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.

View Audit 367241

Corrective Action Plans

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