Corrective Action Plans

Finding 1222669 (2025-007)

Material Weakness 2025

VA

Subrecipient Monitoring Eligibility

2025-007 Auditor’s Recommendation: The entity should strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are identifiable by participant and reconciled to eligibility records. The entity should also establish controls to verify benefit calculations a...

2025-007 Auditor’s Recommendation: The entity should strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are identifiable by participant and reconciled to eligibility records. The entity should also establish controls to verify benefit calculations and ensure assistance is discontinued when eligibility expires, and maintain sufficient documentation to demonstrate compliance with program requirements. Corrective Action: UCM will strengthen internal controls over TANF benefit payments by implementing procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and supporting documentation. UCM has established TANF Eligibility Determination Guidelines, a List of Acceptable Documents, and an Assistance Agreement Form to support eligibility determinations and benefit payment documentation. Per VDSS guidance, once eligibility is established at the beginning of the program, a change in status during the participant’s stay does not disqualify the participant from receiving further services. Felony record documentation is not required in the participant file as felony record status is not part of the eligibility requirement per VDSS. Evidence of review and approval will be retained in the participant file. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Case Managers Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Laura D’Ambrogi, Grants Manager Anticipated Completion Date: Substantially completed as of April 6, 2026. Ongoing payment review, eligibility monitoring, reconciliation, and supervisory review will continue during the program year.

View Audit 406238

Finding 1222668 (2025-006)

Material Weakness 2025

UNITED COMMUNITY MINISTRIES, INC.

VA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

2025-006 Auditor’s Recommendation: UCM should strengthen internal controls over TANF eligibility determinations by developing and implementing written procedures that clearly define the documentation required to support all TANF eligibility criteria. These procedures should require that participant ...

2025-006 Auditor’s Recommendation: UCM should strengthen internal controls over TANF eligibility determinations by developing and implementing written procedures that clearly define the documentation required to support all TANF eligibility criteria. These procedures should require that participant files include sufficient documentation supporting financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, compliance with applicable legal eligibility requirements, and work participation when applicable. In addition, the entity should implement a documented supervisory review and approval process to verify eligibility determinations and supporting documentation prior to the provision of assistance. The entity should also provide training to staff responsible for eligibility determinations to ensure they understand federal TANF documentation requirements and maintain complete and accurate participant files. Corrective Action: UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, applicable legal eligibility requirements, and work participation requirements when applicable. UCM reviewed and discussed the findings with the auditor, Senior Director of Finance, and Chief Program Officer. UCM also reviewed the Virginia Department of Social Services post-training materials on TANF Employment Advancement Eligibility Determination Training, and clarified identified areas of the findings with the Virginia Department of Social Services as they relate to the subrecipient signed contract. UCM designed new Screening Guidelines for incoming program participants, including a documented supervisory review and approval process, which were completed on April 16, 2026. The new screening guidelines require participant files to include sufficient documentation supporting eligibility determinations and require supervisory review before assistance is provided. A supervisor or designated reviewer will verify that the participant file contains the required eligibility documentation, that eligibility criteria have been met, and that the assistance is consistent with TANF requirements, VDSS guidance, the subrecipient contract, and program guidelines. UCM reviewed and trained staff on the new eligibility screening guidelines, acceptable documents, and income requirements on April 28, 2026. Staff responsible for TANF eligibility determinations, case management, direct assistance, and grant compliance will continue to receive training as needed to ensure they understand TANF documentation requirements and maintain complete and accurate participant files. UCM will also periodically monitor participant files to confirm continued compliance and identify any additional training or process improvements needed. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Case Managers VDSS Program Consultant Anticipated Completion Date: Substantially completed as of April 28, 2026. Ongoing implementation, supervisory review, staff training, and monitoring will continue during the program year.

View Audit 406238

Finding 1222667 (2025-005)

Material Weakness 2025

UNITED COMMUNITY MINISTRIES, INC.

VA

Allowable Costs / Cost Principles § 200.403 § 200.404

2025-005 Auditor’s Recommendation: UCM should develop and implement comprehensive written policies and procedures addressing allowability and documentation standards. Controls should ensure only actual costs are charged. Staff responsible for grant accounting should receive Uniform Guidance training...

2025-005 Auditor’s Recommendation: UCM should develop and implement comprehensive written policies and procedures addressing allowability and documentation standards. Controls should ensure only actual costs are charged. Staff responsible for grant accounting should receive Uniform Guidance training. Corrective Action: UCM will develop and implement comprehensive written policies and procedures addressing cost eligibility, documentation standards, and the requirement that only actual costs are charged to Federal awards. The procedures will be designed to ensure costs charged to Federal awards are permitted under the award terms, properly supported, accurately recorded, and consistent with Uniform Guidance requirements. UCM will update its grant accounting procedures to require supporting documentation for all costs charged to Federal awards, including invoices, receipts, payroll records, allocation schedules, contracts, purchase approvals, proof of payment, and other relevant source documents. Estimated, unsupported, or budgeted amounts will not be charged to Federal awards unless specifically permitted by the award terms and adjusted to actual costs within the required reporting period. UCM will also implement a documented review process to confirm that Federal award expenditures are based on actual costs incurred. The review will include verification that the expense was incurred during the grant period, relates to the approved program, is supported by adequate documentation, is charged to the correct funding source, and agrees to the general ledger and supporting records. Evidence of review and approval will be retained with the grant files. Staff responsible for grant accounting, Federal award reporting, payroll allocation, accounts payable, and program budget oversight will receive Uniform Guidance training. Training will include cost eligibility, documentation standards, actual cost requirements, cost allocation, and grant expenditure review procedures. Responsible for Corrective Action: Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Anticipated Completion Date: December 31, 2026

View Audit 406238

Finding 1222666 (2025-004)

Material Weakness 2025

UNITED COMMUNITY MINISTRIES, INC.

VA

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

2025-004 Auditor’s Recommendation: UCM should formalize and document internal control procedures over Federal award expenditures, including documented review and approval processes to ensure compliance with Uniform Guidance. Corrective Action: UCM will formalize and document internal control procedu...

2025-004 Auditor’s Recommendation: UCM should formalize and document internal control procedures over Federal award expenditures, including documented review and approval processes to ensure compliance with Uniform Guidance. Corrective Action: UCM will formalize and document internal control procedures over Federal award expenditures to ensure costs charged to Federal awards are allowable, allocable, reasonable, properly approved, and adequately supported in accordance with Uniform Guidance. Written procedures will be developed for expenditure review and approval, including documentation of business purpose, budget availability, cost eligibility under the award terms, proper account coding, funding source, supporting documentation, and evidence of approval. UCM will also strengthen controls over direct assistance to client expenditures by requiring documentation of client eligibility, assistance type, amount approved, funding source, program approval, finance review, and evidence of payment. Direct assistance expenditures will be reviewed to ensure they are allowable under the Federal award, consistent with program requirements, properly coded, and adequately supported before payment or reimbursement is processed. UCM will also implement a Federal award expenditure checklist or similar review tool to document review before expenditures are paid, posted, or reported. The checklist will include review of allowability, allocability, reasonableness, budget availability, funding source, supporting documentation, approval, and compliance with applicable Federal award requirements. For direct assistance to clients, the checklist will also confirm client eligibility, approved assistance type, required case documentation, and evidence of payment. Staff responsible for Federal award expenditures, direct client assistance, grant accounting, accounts payable, and program budget management will receive training on the updated procedures and Uniform Guidance requirements. Supporting documentation and evidence of review and approval will be retained with the expenditure records. Responsible for Corrective Action: Shruti Jha, Senior Director of Finance Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Anticipated Completion Date: December 31, 2026

View Audit 406238

Finding 1222665 (2025-003)

Material Weakness 2025

UNITED COMMUNITY MINISTRIES, INC.

VA

Allowable Costs / Cost Principles § 200.403 § 200.430

2025-003 Auditor’s Recommendation: UCM should develop and implement comprehensive written policies and procedures addressing time and effort, employee benefits, payroll allocations, and documentation standards. Staff responsible for grant accounting should receive Uniform Guidance training. Correcti...

2025-003 Auditor’s Recommendation: UCM should develop and implement comprehensive written policies and procedures addressing time and effort, employee benefits, payroll allocations, and documentation standards. Staff responsible for grant accounting should receive Uniform Guidance training. Corrective Action: UCM is implementing Insperity, a new Human Resource and Payroll software system, to improve the accuracy and documentation of time allocation, payroll processing, and benefit allocation across programs and funding sources, including the Family Achievement Program federal award. UCM will configure Insperity and related procedures to support time allocation by program, grant, or cost objective, supervisor approval, payroll allocation reporting, and retention of supporting documentation. In addition, UCM will develop and implement written policies and procedures addressing time and effort reporting, employee benefit allocations, payroll allocation methodology, review and approval requirements, and documentation retention standards. These procedures will require that employee benefits charged to the federal award are based on actual benefit costs incurred, rather than budgeted or estimated amounts, unless otherwise permitted by the award terms and adjusted to actual costs within the required reporting period. UCM will establish a review process to ensure payroll and benefit costs charged to the federal award are accurate, allowable, based on actual costs incurred, properly supported, and consistent with Uniform Guidance requirements. Staff responsible for grant accounting, payroll processing, and federal award compliance will receive Uniform Guidance training. Responsible for Corrective Action: Shruti Jha, Senior Director of Finance Deborah Ewell, Director of Human Resources Laura D’Ambrogi, Grants Manager Anticipated Completion Date: September 30, 2026

View Audit 406238

Finding 1222664 (2025-003)

Material Weakness 2025

City of Watertown

SD

Internal Control / Segregation of Duties Questioned Costs Material Weakness

Department of Treasury, Passed through the Department of Agriculture and Natural Resources Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: During the engagement, Eide Bailly LLP noted the annual project and expenditure repor...

Department of Treasury, Passed through the Department of Agriculture and Natural Resources Federal Financial Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: During the engagement, Eide Bailly LLP noted the annual project and expenditure report submitted during the year ended December 31, 2025, was not reviewed prior to submission and had amounts reported that did not agree to the general ledger system of the City. Responsible Individuals: Kristen Bobzien, Chief Financial Officer Corrective Action Plan: The City will put procedures in place to ensure the annual project and expenditure report is reviewed for accuracy prior to submission. Anticipated Completion Date: December 31, 2026

View Audit 406234

Finding 1222661 (2025-001)

Material Weakness 2025

Town of Orange Park, Fl

FL

Procurement, Suspension & Debarment § 200.214

The Town has been duly aware of it responsibilities pertaining to this program and will comply with the program requirements for suspension and debarment including evaluation and documentation for program expenditures.

View Audit 406232

Finding 1222653 (2025-001)

Material Weakness 2025

Ili Senior Housing - Chapel Valley Road, Inc.

WI

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

Required Monthly Deposits Not Made Timely. Criteria: Monthly deposits are required to be made to the replacement reserve account. Condition: Monthly deposits were not made. Deposits were made every few months and total amount deposited ties to the required total deposits for the year. Context: Requi...

Required Monthly Deposits Not Made Timely. Criteria: Monthly deposits are required to be made to the replacement reserve account. Condition: Monthly deposits were not made. Deposits were made every few months and total amount deposited ties to the required total deposits for the year. Context: Required deposits were made but they were not made monthly due to cash flow restraint. Response: The Organization will make the required deposits monthly if cash flow allows. Management expects these corrective actions to ensure future compliance with applicable federal and HUD reporting requirements.

View Audit 406220

Finding 1222652 (2025-002)

Material Weakness 2025

Score Association

VA

Reporting Questioned Costs

SCORE believes that this finding stems from exceptional circumstances that occurred during fiscal year 2025 related to the interruption of federal funding. SCORE expensed the last of the authorized fiscal year 2025 federal award funds in March 2025 and is still awaiting authorization for the remaind...

SCORE believes that this finding stems from exceptional circumstances that occurred during fiscal year 2025 related to the interruption of federal funding. SCORE expensed the last of the authorized fiscal year 2025 federal award funds in March 2025 and is still awaiting authorization for the remainder of the appropriated funds under the fiscal year 2025 award. As a result, SCORE was not able to continue submitting monthly draw requests that included the corresponding Detailed Expenditure Worksheets (DEWs). However, in accordance with the Notice of Award requirements, SCORE continued to prepare and submit quarterly financial reports reflecting expenditures that had been earmarked for federal reimbursement. Because the corresponding DEWs and draw requests could not be submitted while federal funding authorization remained pending, these reports could not be fully reconciled to the DEWs that have not yet been filed. Management acknowledges the auditors’ recommendation and will strengthen internal controls around the reconciliation of monthly and quarterly reporting. SCORE will implement enhanced reconciliation procedures to ensure that future reimbursement requests are fully reconciled prior to submission and will establish a documented contingency procedure for reporting periods in which federal funding authorization or reimbursement processing is delayed.

View Audit 406219

Finding 1222649 (2025-001)

Material Weakness 2025

Score Association

VA

Procurement, Suspension & Debarment § 200.214 § 200.318

SCORE acknowledges the auditors’ recommendation and confirms that procedures are already in place to verify new vendors against the SAM.gov suspension and debarment database prior to engagement. Management agrees that this procedure should be extended to include periodic verification for contract re...

SCORE acknowledges the auditors’ recommendation and confirms that procedures are already in place to verify new vendors against the SAM.gov suspension and debarment database prior to engagement. Management agrees that this procedure should be extended to include periodic verification for contract renewals and multi-year vendor relationships. SCORE will also update its vendor compliance procedures to require documented SAM.gov verification at the time of vendor onboarding and periodically thereafter for continuing vendors and will implement a centralized tracking mechanism to document verification dates.

View Audit 406219

Finding 1222646 (2025-007)

Material Weakness 2025

Jones County Junior College

MS

Student Financial Aid Subrecipient Monitoring Special Tests & Provisions § 200.303

The College acknowledges the finding and agrees that required notifications to students must be provided prior to the disbursement of Title IV funds. The condition resulted from the absence of formal procedures and controls to ensure timely notification and documented review. The College is in the p...

The College acknowledges the finding and agrees that required notifications to students must be provided prior to the disbursement of Title IV funds. The condition resulted from the absence of formal procedures and controls to ensure timely notification and documented review. The College is in the process of implementing enhanced controls over student notification procedures. Formal policies and procedures will be established to ensure that notifications are generated and delivered prior to disbursement, including defined timing, content, and documentation requirements. The College will engage third-party consultants and implement system enhancements to improve the timing and sequencing of notifications and disbursements. In addition, the College will implement monitoring procedures, including tracking of notification and disbursement dates and documented supervisory review, to ensure compliance with timing requirements and timely identification and resolution of exceptions. Accounting, independent of the Office of Financial Aid, will perform a final review to verify that notifications are issued prior to disbursement and that established procedures are consistently followed. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that required notifications are provided timely and in accordance with federal requirements, and to prevent recurrence

View Audit 406216

Finding 1222644 (2025-006)

Material Weakness 2025

Jones County Junior College

MS

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

The College acknowledges the finding and agrees that verification procedures must include documented evidence of completion and supervisory review. The condition resulted from the absence of formal procedures and lack of retained documentation evidencing completion and review of verification activit...

The College acknowledges the finding and agrees that verification procedures must include documented evidence of completion and supervisory review. The condition resulted from the absence of formal procedures and lack of retained documentation evidencing completion and review of verification activities. The College is in the process of implementing enhanced controls over verification procedures. Formal policies and procedures will be established to define responsibilities, documentation requirements, and supervisory review expectations. Each verification file will require documented evidence of completion and review, including electronic sign-off or system-based approval. In addition, the College will implement quality control measures, including systematic validations and periodic supervisory reviews, with documentation retained to evidence the scope and results of such reviews. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that verification procedures are consistently applied, properly documented, and subject to appropriate review, and to prevent recurrence.

View Audit 406216

Finding 1222642 (2025-005)

Material Weakness 2025

Jones County Junior College

MS

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The College acknowledges the finding and agrees that Return of Title IV Funds (R2T4) calculations and related return activity must be accurately calculated, properly documented, and fully traceable. The condition resulted from the absence of formal procedures, lack of documented supervisory review, ...

The College acknowledges the finding and agrees that Return of Title IV Funds (R2T4) calculations and related return activity must be accurately calculated, properly documented, and fully traceable. The condition resulted from the absence of formal procedures, lack of documented supervisory review, and insufficient documentation and reconciliation of student-level return activity. The College is in the process of implementing enhanced controls over the R2T4 process. A monthly structured workflow has been established whereby the Office of Financial Aid prepares and provides a detailed listing of students subject to R2T4 calculations, including institutional return amounts. Accounting independently reviews and verifies the calculated return amounts and processes the return through the federal system, with documented review and approval. The College has eliminated undocumented manual netting adjustments and requires that all R2T4 returns be recorded as distinct transactions supported by a standardized documentation package, including studentlevel calculations, withdrawal determination dates, and institutional return amounts. All activity is maintained in a centralized electronic repository to ensure a complete audit trail. In addition, the College is formalizing written procedures to define roles and responsibilities, establish documentation standards, and require documented supervisory review and approval. Periodic reconciliations will be performed to ensure that student-level return amounts agree to system activity and federal cash activity. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that R2T4 calculations and returns are accurate, properly documented, fully traceable, and compliant with federal requirements, and to prevent recurrence.

View Audit 406216

Finding 1222640 (2025-004)

Material Weakness 2025

Jones County Junior College

MS

Student Financial Aid Subrecipient Monitoring Reporting § 200.303

The College acknowledges the finding and agrees that reporting to the Common Origination and Disbursement (COD) system must be accurate, complete, and submitted within required timeframes. The condition resulted from the absence of formal procedures and controls to validate key data elements and mon...

The College acknowledges the finding and agrees that reporting to the Common Origination and Disbursement (COD) system must be accurate, complete, and submitted within required timeframes. The condition resulted from the absence of formal procedures and controls to validate key data elements and monitor reporting timeliness. The College is in the process of implementing enhanced controls over COD reporting. The Office of Financial Aid will develop and formalize written procedures governing the reconciliation of awarding and disbursement activity with COD reporting, including defined responsibilities, documentation standards, and review requirements. The College will also engage third-party consultants to review current processes and assist with system enhancements. System configuration and process improvements will be implemented to support the automation of award and disbursement reporting through PeopleSoft. The Office of Financial Aid will implement quality control measures, including systematic validations and documented supervisory review, to ensure accuracy, consistency, and compliance in COD reporting. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that COD reporting is accurate, timely, and properly controlled, and to prevent recurrence.

View Audit 406216

Finding 1222638 (2025-003)

Material Weakness 2025

Jones County Junior College

MS

Student Financial Aid Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The College acknowledges the finding and agrees that Cost of Attendance and Satisfactory Academic Progress determinations must be calculated, documented, and reviewed in accordance with federal requirements. The condition resulted from reliance on manual processes, lack of retained supporting docume...

The College acknowledges the finding and agrees that Cost of Attendance and Satisfactory Academic Progress determinations must be calculated, documented, and reviewed in accordance with federal requirements. The condition resulted from reliance on manual processes, lack of retained supporting documentation, and absence of independent review and approval. The College is in the process of implementing enhanced controls over COA and SAP determinations. Formal policies and procedures will be established to define methodologies, documentation requirements, and responsibilities for preparation and review. The College will work with Information Technology and third-party consultants to enhance system configuration and develop automated processes to support calculation and retention of COA and SAP determinations within a controlled environment. In addition, the College will implement quality control measures, including a COA review committee, systematic validations and documented supervisory review, and will retain sufficient supporting documentation to allow for independent recalculation and verification of eligibility determinations. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that eligibility determinations are accurate, properly supported, and compliant with federal requirements, and to prevent recurrence.

View Audit 406216

Finding 1222636 (2025-002)

Material Weakness 2025

Jones County Junior College

MS

Cash Management Student Financial Aid Matching / Level of Effort / Earmarking § 200.302 § 200.303 § 200.305

The College acknowledges the finding and agrees that formal cash management controls are required to ensure that Title IV funds are drawn only for immediate cash needs and are properly supported and documented. The condition resulted from the absence of documented procedures and inconsistent executi...

The College acknowledges the finding and agrees that formal cash management controls are required to ensure that Title IV funds are drawn only for immediate cash needs and are properly supported and documented. The condition resulted from the absence of documented procedures and inconsistent execution of draw preparation, review, approval, and reconciliation processes. The College is in the process of implementing enhanced controls over cash management. Formal written procedures are being established to govern draw calculations, timing, approvals, supporting documentation, reconciliation requirements, and identification and return of excess cash. A standardized draw file will be maintained for each draw, including supporting student-level disbursement detail, reconciliation to eligible expenditures, and documented supervisory approval. The College will also perform and document monthly reconciliations between student disbursement records and federal cash activity. Cash balances will be monitored to ensure funds are drawn only for immediate needs and that excess cash is identified and returned, as necessary. Implementation of these procedures began in April 2026 and was not in place for the full fiscal year. Fiscal year 2026 represents a transition period during which controls are being implemented and refined. Full implementation is expected for the 2026–2027 award year. These actions are intended to ensure that draw amounts are accurate, properly supported, and compliant with federal requirements, and to prevent recurrence.

View Audit 406216

Finding 1222634 (2025-004)

Material Weakness 2025

Center for Cultural & Technical Interchange Between East & West, INC

HI

Allowable Costs / Cost Principles § 200.430

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: Problem The financial audit conducted by N&K identified that there were two (2) incorrect deduction amounts that were entered into the HRIS system, resulting in an overcharge to the employee...

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: Problem The financial audit conducted by N&K identified that there were two (2) incorrect deduction amounts that were entered into the HRIS system, resulting in an overcharge to the employee. Upon investigation, it was determined that the HR Administrator updated the wrong benefits deduction entry, which caused an incorrect overcharge for the employee’s life insurance deduction and an incorrect undercharge to their long-term disability insurance deduction. The incorrect charges occurred over a span of 15 months to a total overage of $913.59, for which the employee was not reimbursed. Root Cause The error occurred during the organization’s benefits carrier switch from Prudential Financial to The Standard. Their existing process—where the Administrator inputs changes and the Assistant performs a post-entry review—failed to detect the error, resulting in a finding within the auditor’s report. The issue appears to stem from a combination of process and control weaknesses: • Manual data entry error by the Administrator • Ineffective secondary manual review, likely due to: o Lack of a standardized checklist or validation criteria o Insufficient sampling or inconsistent spot-check methodology • Lack a system-based validation controls within the HRIS system (e.g., thresholds, alerts) • Limited accountability clarity for final verification • Lack of periodic audits in case errors are missed Immediate actions to address the current issue and mitigate employee impact • Calculate and process reimbursement for the overcharged employee (completed) • Communicate transparently with the affected employee regarding: o Nature of the error o Correction made o Reimbursement payment • Conduct a targeted audit of recent deduction changes to identify any similar errors (completed) Corrective Action Plan (Preventive Controls) To prevent future occurrences from happening, unit will implement the following changes to its administrative procedures: 1. Standardized Data Entry Protocol The unit will utilize its HR Action Form as a standard processing mechanism for benefit deduction changes made within the HRIS, including:• Source documentation verification (e.g., enrollment forms, carrier files) • Confirmation of deduction amount and effective date This will require both the processor and the reviewer to initial and certify that the change was accurately completed, thus strengthening its review process. 2. Enhancing review procedure for multiple changes done at the same time The unit will replace its previous “spot check” review process with a structured verification process that mirrors its semi-monthly timesheet report for payroll. This new report will include: • The processor documenting all deductions or changes made • The processor including supporting documentation • The auditor completing a 100% review to confirm work accuracy and cross-verification against source documents • The Director providing a final spot-check and sign-off It is important to acknowledge that these enhanced controls may introduce some operational trade-offs. In the short term, the shift to 100% review and additional dual-verification tasks will likely increase processing time and workload redundancy for both the Administrator and Assistant. There is also a risk of workflow bottlenecks, particularly during high-volume periods such as open enrollment or payroll cutoffs. Closing The implementation of new corrective and preventive measures will establish a more disciplined and reliable control environment around the East-West Center’s benefits administration. By formalizing data entry protocols, strengthening independent review, and introducing layered validation controls, the unit can significantly reduce the likelihood of this occurrence (or other-related HRIS data entry errors) while improving overall data integrity and employee trust. The proposed changes will enhance audit readiness and operational transparency for the Human Resources team.Contact Person: Human Resources Director Anticipated Completion Date: Procedures have been implemented as of report issuance date 32

View Audit 406213

Finding 1222633 (2025-003)

Material Weakness 2025

Center for Cultural & Technical Interchange Between East & West, INC

HI

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: East-West Center will designate the International Programs Specialist (coordinator of the Graduate Degree Fellowships) to prepare the list of selected students to be offered scholarships dem...

View of Responsible Officials: Management agrees with the finding and recommendation. Corrective Action Plan: East-West Center will designate the International Programs Specialist (coordinator of the Graduate Degree Fellowships) to prepare the list of selected students to be offered scholarships demonstrating clearly that the selections meet the ratio requirement. The Dean of the Education Program will be required to sign off on the list, checking to ensure that the ratio of students meets our designated mandate. If students decline our initial offer, each alternate also will be vetted by the Dean to ensure the balance is maintained. If there is funding uncertainty up until the date required to send invitations, and a different funding source is used as an alternative or backstop, the program will bring these students on a J-visa so that they are able to shift to Federal funds at a later date to ensure that the ratio is maintained. 27 Contact Person: Director and Dean of Professional Development and Education Programs Anticipated Completion Date: May 2026 28

View Audit 406213

Finding 1222632 (2025-002)

Material Weakness 2025

Center for Cultural & Technical Interchange Between East & West, INC

HI

Cash Management § 200.305

View of Responsible Officials: Management is cognizant of federal regulations surrounding cash management and has procedures in place to minimize the time elapsing between the transfer of funds from the awarding agency and the disbursement of the funds. In this particular case, management received d...

View of Responsible Officials: Management is cognizant of federal regulations surrounding cash management and has procedures in place to minimize the time elapsing between the transfer of funds from the awarding agency and the disbursement of the funds. In this particular case, management received direction from relevant stakeholders recommending the advance drawdown of cash. • Management met with board members in September 2025 to discuss the impact of a potential government shutdown and received strategic guidance from the board to draw down the remaining funds to ensure that funding would be available for staff salaries. The Center’s staff union requires the Center to provide 120 days’ notice prior to layoff and the board wanted to ensure that funding would be available for the 120-day period, if necessary. • Management met with contracted financial advisors who encouraged management to draw down the remaining funds. The advisors are certified public accountants, well versed in regulations regarding federal funds. • Management received an email from the awarding agency representative recommending drawdown of the remaining funds; the agency provided the wording for the Center to use to justify the advance drawdown. A confirmation email was sent to the awarding agency after the draw was performed. 25 Corrective Action Plan: In the event of another government shutdown jeopardizing immediate funding, the Center will ensure that written guidance is received by the awarding agency, the Board of Governors, or the Center President, prior to initiating the drawdown. Contact Person: Chief Operating Officer Anticipated Completion Date: May 2026

View Audit 406213

Finding 1222625 (2025-005)

Material Weakness 2025

Disability Rights South Dakota

SD

Questioned Costs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Finding No. 2025-005: Matching Compliance Controls Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2026

View Audit 406207

Finding 1222623 (2025-004)

Material Weakness 2025

Disability Rights South Dakota

SD

Cash Management

Finding No. 2025-004: Federal Program Expenditure Tracking Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will establish cash management internal control and review processes and maintain adequate documentation for reimbursement requests and ...

Finding No. 2025-004: Federal Program Expenditure Tracking Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will establish cash management internal control and review processes and maintain adequate documentation for reimbursement requests and federal grant reports. Anticipated Completion Date: September 30, 2026

View Audit 406207

Finding 1222620 (2025-002)

Material Weakness 2025

Disability Rights South Dakota

SD

Reporting

Finding No. 2025-002: Adjustments to Financial Statements and Schedule of Expenditures of Federal Awards Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will seek outside consulting to train existing personnel on accrual accounting and assista...

Finding No. 2025-002: Adjustments to Financial Statements and Schedule of Expenditures of Federal Awards Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will seek outside consulting to train existing personnel on accrual accounting and assistance with year-end adjustments. Anticipated Completion Date: September 30, 2026

View Audit 406207

Finding 1222617 (2025-001)

Material Weakness 2025

Pennsylvania Association of Regional Food Banks

PA

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and C...

Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and Cause: There were two instances out of 40 distributions tested where this signoff was not completed. Due to the hectic environment at the lead agencies during food distribution day, oversights have occurred when obtaining the required client signoff. Statement of Concurrence or Nonconcurrence: PARF management has reviewed the 2025-001 finding and concurs with the recommendations as stated. Corrective Action: PARF has an extensive training process in place for lead agencies, in relation to grant award compliance requirements, which includes the provision of training manuals and monthly phone calls to review matters. In addition, PARF provides updates to the lead agencies as new or amended requirements are enacted. Further, PARF does periodic reviews of the lead agencies and completes the biennial review Form 502035 CSFP Management Evaluation. PARF will continue to reiterate the required signoff process with the lead agencies during phone calls, training session and reviews. In addition for FY 2026 PARF will be conducting a mandatory webinar to ensure all the lead agencies are understanding the procedure and why it is important for 100 percent accuracies -https://docs.google.com/presentation/d/1YZgcq7SY4DmvhYrKZE8sp-NDhpuzn827PZDZ0xAKDw/edit?usp=sharing

View Audit 406206

Finding 1222614 (2025-001)

Material Weakness 2025

Healthy Start

IL

Cash Management Eligibility

Healthy Start has implemented procedures to double check coding and input with final review, first by initial review of parent application by Program Director who codes, then by review of parent application by Admin Asst for accuracy and then by input of parent application in data base where input a...

Healthy Start has implemented procedures to double check coding and input with final review, first by initial review of parent application by Program Director who codes, then by review of parent application by Admin Asst for accuracy and then by input of parent application in data base where input and classification is reviewed for correctness.

View Audit 406204

Finding 1222605 (2025-002)

Material Weakness 2025

Lee Health System, Inc.

FL

Internal Control / Segregation of Duties Reporting Questioned Costs § 200.512

2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of H...

2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Assistance Listing Name: Medicaid Cluster – Medical Assistance Program Management will implement and maintain the following corrective actions:  Management has added a validation step with a secondary review by another team member to validate that all steps relating to submission have been clearly completed.  Management has also added this to our reporting checklist that is part of the Single Audit Process Narrative. Responsible Party: Controller, under the oversight of the Vice President of Financial Services/Chief Financial Officer, in coordination with the Grants function. Completion date: June 30, 2026

View Audit 406201

Corrective Action Plans

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