Corrective Action Plans

Finding 1223692 (2025-003)

Material Weakness 2025

Lapeer County

MI

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Significant Deficiency § 200.403

2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before i...

2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before indirect costs are charged to the grant. A grant expenditure tracking process will be established to monitor direct and indirect costs against the approved budget throughout the grant period. The Chief Financial Officer will review indirect cost calculations and budget-to-actual expenditures monthly to ensure expenditures remain within approved budget limitations and comply with applicable federal regulations and grant requirements. This CMHSP will create grant management policies and procedures, outside of the County of Lapeer’s grant management policy, to include documented reviews of indirect cost calculations, monthly budget monitoring, and supervisory approval of grant expenditures to ensure compliance with federal awards. Responsible Party: Emma McQuillan, Chief Financial Officer Anticipated Completion Date: 09/30/2026

View Audit 407192

Finding 1223691 (2025-002)

Material Weakness 2025

Lapeer County

MI

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Subrecipient Monitoring § 200.317 § 200.318 § 200.327

2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards...

2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Responsible Party: Emma McQuillan, Chief Financial Officer Completion Date: 12/5/2024

View Audit 407192

Finding 1223689 (2025-003)

Material Weakness 2025

Second Harvest Community Foodbank

MO

Procurement, Suspension & Debarment

We agree with the auditor’s comments and the following action has been taken to improve this situation. Second Harvest staff have built a comprehensive vendor list to properly evaluate vendors through the procurement process and developed a schedule to review vendors in accordance with our Financial...

We agree with the auditor’s comments and the following action has been taken to improve this situation. Second Harvest staff have built a comprehensive vendor list to properly evaluate vendors through the procurement process and developed a schedule to review vendors in accordance with our Financial Policies and Procedures on a regular basis based on the anticipated and/or historical aggregate spend for goods and services. Second Harvest updated its Financial Policies and Procedures as of March 2026, which includes the guiding process, review of the organizational practices around procurement, and a new threshold of $15k. This corrective action was implemented January 1, 2026.

View Audit 407179

Finding 1223684 (2025-004)

Material Weakness 2025

Second Harvest Community Foodbank

MO

Cash Management Reporting

We agree with the auditor’s comments and the following action has been taken to improve this situation. Beginning October 1, 2025, a cost allocation policy was implemented which addresses direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a ...

We agree with the auditor’s comments and the following action has been taken to improve this situation. Beginning October 1, 2025, a cost allocation policy was implemented which addresses direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a spreadsheet was developed to better distribute costs appropriately across all federal programs operated by Second Harvest and efforts supported through additional funding sources.

View Audit 407179

Finding 1223683 (2025-002)

Material Weakness 2025

Second Harvest Community Foodbank

MO

We agree with the auditor’s comments and the following action has been taken to improve this situation. Beginning October 1, 2025, a cost allocation policy was implemented which addresses direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a ...

We agree with the auditor’s comments and the following action has been taken to improve this situation. Beginning October 1, 2025, a cost allocation policy was implemented which addresses direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a spreadsheet was developed to better distribute costs appropriately across all federal programs operated by Second Harvest and efforts supported through additional funding sources.

View Audit 407179

Finding 1223677 (2025-002)

Material Weakness 2025

City of Minneapolis

MN

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

Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Correct...

Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City concurs with this finding. City has hired additional resources to perform review of subrecipient transactions. On a monthly basis, the new position will review system generated reports to timely capture reportable subrecipient transactions. Additionally, the City has an ongoing quarterly meeting with all grant managers. Training will be provided to grant managers to ensure proper identification of subrecipient contracts and proper entry into the SAM.gov system. Anticipated Completion Date: December 31, 2026

View Audit 407178

Finding 1223676 (2025-003)

Material Weakness 2025

City of Minneapolis

MN

Questioned Costs Cash Management HUD Housing Programs § 200.303

Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges...

Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges this finding. City has communicated directly with Housing and Urban Development for clarification on reporting requirements and intends on following the updated guidance they provided. Anticipated Completion Date: July 31, 2026

View Audit 407178

Finding 1223674 (2025-001)

Material Weakness 2025

Sain Mary's Home for the Elderly, Inc.

PR

Management is currently evaluating the alternatives to cover the underfunded amount

View Audit 407177

Finding 1223673 (2025-002)

Material Weakness 2025

Bakerripley

TX

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 200...

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Department of Agriculture, Assistance Listing #: 10.561 – State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP Cluster), Passed through Houston-Galveston Area Council, Contract Number: 20020, Contract Year: 10/01/25 - 09/30/26. Condition and context: During our testing of 40 federal and state payments to childcare providers under the Houston-Galveston Area Council contract, we noted that 1 childcare provider was paid at an incorrect provider rate resulting in an overpayment of $9.10. Recommendation: Re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Corrective action: BakerRipley will re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026

View Audit 407173

Finding 1223672 (2025-001)

Material Weakness 2025

Bakerripley

TX

Matching / Level of Effort / Earmarking Questioned Costs

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contra...

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25. Condition and context: During the planning phase of the audit, management disclosed that childcare providers were paid $3.6 million in duplicate childcare assistance payments in July 2025. As of May 15, 2026, $2.5 million of the duplicate payments have been recovered. Recommendation: Implement prevention procedures to identify duplicate payments prior to payment. Corrective action: BakerRipley has reviewed internal processes and procedures to determine the cause and implement prevention procedures related to the duplication of payments prior to payment. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026

View Audit 407173

Finding 1223650 (2025-001)

Material Weakness 2025

Scotts Bluff County Nebraska

NE

Internal Control / Segregation of Duties Questioned Costs Reporting

SEGREGATION OF ACCOUNTING FUNCTIONS Recommendation: The County should be aware of the inherent risks associated with improper segregation of accounting functions. The County should also develop mitigating controls to reduce the risk of errors or fraud associated with improper segregation of accounti...

SEGREGATION OF ACCOUNTING FUNCTIONS Recommendation: The County should be aware of the inherent risks associated with improper segregation of accounting functions. The County should also develop mitigating controls to reduce the risk of errors or fraud associated with improper segregation of accounting functions. Action Taken: The County has assessed the benefits and costs associated with proper segregation of duties for all County departments and offices and has determined that cost would outweigh any benefits received. The County understands the inherent risks associated with improper segregation of accounting functions. Action has been taken to ensure timely deposits to the General Fund from the accounts held by individual departments, and County Management has communicated the need to be transparent regarding the transactions handled within these accounts. The County requires monthly reporting to the Board of Commissioners for various department officials to ensure transactions are recorded, and potential errors and irregularities are identified on a timely basis. The County will continue to review accounting procedures and processes to further mitigate this internal control deficiency whenever possible and feasible.

View Audit 407166

Finding 1223648 (2025-001)

Material Weakness 2025

Town of Wolcott, Vermont

VT

Procurement, Suspension & Debarment § 200.214 § 200.317 § 200.327

Corrective Action Plan Contact Person: Belinda Harris Clegg, Wolcott Town Clerk & Treasurer Corrective Action: The Selectboard will update their Purchasing Policy to include checking Sam.gov to confirm if a contractor has not been debarred or suspended from receiving federal funds and to request a S...

Corrective Action Plan Contact Person: Belinda Harris Clegg, Wolcott Town Clerk & Treasurer Corrective Action: The Selectboard will update their Purchasing Policy to include checking Sam.gov to confirm if a contractor has not been debarred or suspended from receiving federal funds and to request a Suspension and Debarment certification from the contractor. Anticipated Completion Date: April 30, 2026

View Audit 407163

Finding 1223645 (2025-001)

Material Weakness 2025

United Cerebral Palsy Housing Development Fund Corporation, Inc.

NY

Reporting HUD Housing Programs

Finding Number: 2025-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the...

Finding Number: 2025-001 Reporting – Noncompliance (Control Deficiency) Programs: U.S. Department of Housing and Urban Development - Project Based Rental Assistance (PBRA) (Section 8 Project-Based Cluster), Award Listing Number 14.195. Planned Corrective Action: The Corporation acknowledges that the 2025 data collection form and REAC filing were not filed timely. The planned correction plan is to file the 2025 data collection form and REAC filing upon the issuance of the Uniform Guidance financial statements and ensure that future data collection forms and REAC filing are submitted timely. Person Responsible: A’isha Torrence, Chief Financial Officer Expected Completion Date: July 2026

View Audit 407160

Finding 1223643 (2025-003)

Material Weakness 2025

St. Marys City School District

OH

School Nutrition Programs Cash Management Eligibility

A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any change...

A 100% review of applications was completed on October 10, 2025. The Food Service Supervisor will run an original direct certification before school starts and import that into Linq system. A 100% verification is completed in the fall. Each month a new direct certification is ran to catch any changes.

View Audit 407155

Finding 1223641 (2025-015)

Material Weakness 2025

Canadian County

OK

Subrecipient Monitoring § 200.1 § 200.303 § 200.329 § 200.344

The Board of County Commissioners will ensure that the reports are accurate and reported in the proper period.

View Audit 407153

Finding 1223640 (2025-012)

Material Weakness 2025

Canadian County

OK

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

The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.

View Audit 407153

Finding 1223639 (2025-010)

Material Weakness 2025

Canadian County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring Internal Control / Segregation of Duties

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...

We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.

View Audit 407153

Finding 1223630 (2025-002)

Material Weakness 2025

City of Shawnee, Oklahoma

OK

Reporting Internal Control / Segregation of Duties

2025-002 — Filing with the State Auditor and Federal Audit Clearinghouse Finance Department 16 W. 9th St. Shawnee, OK 74801 ShawneeOK.org Condition: The city did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year endingiune 30, 2025....

2025-002 — Filing with the State Auditor and Federal Audit Clearinghouse Finance Department 16 W. 9th St. Shawnee, OK 74801 ShawneeOK.org Condition: The city did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year endingiune 30, 2025. Additionally, the city did not submit its audit report to the FAC within nine months from the year ending June 30, 2025. In conjunction with our FY2025 single audit, please see the City's corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines to remain compliant with requirements. Management will try to correct their timeliness and file within the appropriate deadlines going forward. Expected completion date: FY26 Audit

View Audit 407127

Finding 1223629 (2025-001)

Material Weakness 2025

Sain Just Home for the Elderly, Inc.

PR

Management is currently evaluating the alternatives to cover the underfunded amount

View Audit 407124

Finding 1223628 (2025-001)

Material Weakness 2025

Town of Stoughton

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...

The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director

View Audit 407123

Finding 1223626 (2025-001)

Material Weakness 2025

Indiana Diaper Bank, Inc.

IN

Material Weakness Reporting Equipment & Real Property Management

Finding 2025-001 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, net assets, reven...

Finding 2025-001 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, net assets, revenues, deferred revenue, and related activity accounts. These adjustments were proposed by the auditors and subsequently recorded by management in order to fairly present the financial statements in accordance with generally accepted accounting principles. The extent and materiality of the adjustments indicate that the Organization's existing closing procedures were insufficient to identify and correct errors prior to the audit. Corrective Actions Taken or Planned: A Part-Time Accounting Manager was hired in October 2025 to assist with financial reporting and documentation. The Organization implemented a review and sign-off process for financial reports at board meetings. The Organization will develop a financial close calendar with clear deadlines. We will create a standard operating procedure for account reconciliations, journal entries, and financial reporting with assignments to specific staff.

View Audit 407121

Finding 1223625 (2025-004)

Material Weakness 2025

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.

View Audit 407121

Finding 1223624 (2025-003)

Material Weakness 2025

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Internal Control / Segregation of Duties Eligibility § 200.303

Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit i...

Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.

View Audit 407121

Finding 1223623 (2025-002)

Material Weakness 2025

Indiana Diaper Bank, Inc.

IN

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430

Finding 2025-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, for 7 months of the year, it did not maintain sufficient documentation to support the level of effort charged to the ...

Finding 2025-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, for 7 months of the year, it did not maintain sufficient documentation to support the level of effort charged to the award, as required by federal regulations. While staff members are required to complete timesheets, the format did not capture the level of detail needed to substantiate payroll allocations to federal programs. Additionally, there was no formal process for supervisory review and approval of these timesheets. Although no overcharges or double-dipping were identified, the lack of adequate documentation results in known and likely questioned costs due to noncompliance with documentation requirements. A new system was implemented in August 2025 which improved the deficiencies and compliance matters for the remainder of the year. Corrective Actions Taken or Planned: The Organization started using features within Gusto beginning in August 2025 that capture employee name, pay period, hours worked by funding source, detailed notes (if applicable) and supervisory approval. The Organization trained all staff whose salaries are charged in whole or in part to grants on documentation and time allocation requirements. Monthly timesheets charged to grants are reviewed before submission for reimbursement. All timesheets require approval by a supervisor before payroll is processed and the final payroll requires two approvals by the CEO. Accounting Manager and/or the Development Manager. The Organization will conduct quarterly internal reviews to ensure compliance and adjust as needed.

View Audit 407121

Finding 1223615 (2025-001)

Material Weakness 2025

Castle Rock Irrigation District

NE

Matching / Level of Effort / Earmarking

Program: WaterSMART (Assistance Listing No. 15.507) Compliance Requirement: Matching Corrective Action Planned: The District will establish and maintain a grant monitoring process for all federally funded projects that include matching requirements. Management will maintain a grant tracking workshee...

Program: WaterSMART (Assistance Listing No. 15.507) Compliance Requirement: Matching Corrective Action Planned: The District will establish and maintain a grant monitoring process for all federally funded projects that include matching requirements. Management will maintain a grant tracking worksheet documenting cumulative project expenditures, federal funding received, and non-federal matching contributions. Prior to submitting reimbursement requests or drawing federal funds, management will review the tracking worksheet to verify compliance with applicable cost-sharing requirements. Management will also review grant award documents at the outset of each project and periodically throughout the grant period to ensure all compliance requirements, including matching provisions, are understood and followed. Responsible Official: Board President and District Management Planned Completion Date: Implemented upon issuance of the audit report and applicable to all future federal grant awards.

View Audit 407113

Corrective Action Plans

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