Corrective Action Plans

Finding 1223643 (2025-003)

Material Weakness 2025

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

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 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

Finding 1223614 (2025-001)

Material Weakness 2025

Mt. Zion Suburban Apartments, Inc. 073 35137

IN

Management will provide documentation to the auditors in a timely manner in order to complete the audit prior to the deadline.

View Audit 407094

Finding 1223613 (2025-004)

Material Weakness 2025

Municipality of Corozal

PR

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.510

Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Respon...

Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Responsible Officials: Finance Director, Director of Information Systems and the Municipal Advisor Management's Response & Corrective Action Plan: Concurrence with the Findings: The Management of the Municipality of Corozal concurs with the conditions and recommendations outlined in Findings 2025-001 and 2025-004 We acknowledge that the recent migration of our core accounting system compromised the system's operational and technical capacity to generate balanced trial balances, reconcile subsidiary ledgers, and streamline the automatic production of the Schedule of Expenditures of Federal Awards (SEFA). Corrective Actions to be Implemented: To resolve these deficiencies systematically and ensure full compliance with Government Auditing Standards and the Uniform Guidance (2 CFR 200), the Municipality will execute the following action plan within a strict 120-day timeframe: 1. System Re-alignment & Expert Remediation (Led by: Director of Information Systems and the Municipal Advisor): The Municipality will immediately retain specialized software implementation engineers and municipal accounting consultants to trace the migration mapping errors. This team will re-align the platform's database structure to correct the corrupted historical financial data and prior-period balances. 2. Opening Balance Reconstruction (Led by: Finance Director & Municipal Advisor): A formal data-clearing project will be established to reconstruct, cross-reference, and validate all opening balances transferred from the legacy system against the prior year's audited financial statements to restore data integrity. 3. Interim Manual Tracking for Federal Programs (Led by: Finance Director): To address the risks highlighted in Finding 2025-004 the Finance Department will immediately implement an interim manual spreadsheet tracking matrix. This will ensure all federal expenditures across all active Assistance Listings (ALN) are manually reconciled with federal drawdowns and physical invoices until the core accounting database is completely functional. 4. Closing Controls & Migration Policies (Led by: Joint Committee): We will design and implement rigid monthly closing routines and formal trial balance reviews. Furthermore, we will establish strict IT transition frameworks requiring dual-system running periods and mandatory data-integrity sign-offs before any future application or ledger upgrades are deployed. Should you have any questions or require additional information, please do not hesitate to contact the undersigned at (787) 859-3060, ext. 1703. Sincerely Jose A Rivera Miranda Finance Director

View Audit 407087

Finding 1223600 (2025-001)

Material Weakness 2025

Welfare Reform Liaison Project

NC

Reporting § 200.512

Name of contact person: Oliver Bowie, Finance Director Corrective Action: Management will review its internal control procedures to ensure all Single Audits are completed and submitted within the required deadlines. Proposed Completion Date: The Board will implement the above procedure immediately.

View Audit 407083

Finding 1223599 (2025-001)

Material Weakness 2025

Dayton's Bluff Neighborhood Housing Service, Inc.

MN

Reporting Subrecipient Monitoring Material Weakness

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 202...

Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2025 – December 31, 2025 The findings from the December 31, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing

View Audit 407076

Finding 1223598 (2025-002)

Material Weakness 2025

The Women's Safe House

MO

Allowable Costs / Cost Principles Cash Management Eligibility § 200.403

View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain th...

View of Responsible Officials and Corrective Actions: We agree with the auditor's recommendation. Although the referenced invoices were reviewed by the CEO from the vendor for eligibility and reasonableness upon receipt of the automatic e-mailed invoice, there was no procedure to print and retain this documentation in the accounting files for Instacart invoices. Effective June 1, 2026, each month the Director of Finance will compare a checklist of all credit charges to the physical copies prior to filing and obtain any missing invoices as part of the monthly closing process.

View Audit 407064

Finding 1223592 (2025-002)

Material Weakness 2025

Metropolitan Development Council

WA

Special Tests & Provisions Allowable Costs / Cost Principles Eligibility

See pdf of corrective action plan

View Audit 407034

Finding 1223590 (2025-001)

Material Weakness 2025

Metropolitan Development Council

WA

Eligibility Significant Deficiency Internal Control / Segregation of Duties

See pdf of corrective action plan

View Audit 407034

Finding 1223584 (2025-002)

Material Weakness 2025

Upham's Corner Health Committee, Inc.

MA

Eligibility Special Tests & Provisions

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical record...

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should provide training and education to front desk staff related to the EMR and the process for collecting and retaining family size and income information in addition to inputting it into the electronic medical records. We also recommend enhancing any current internal audits of patient visits to determine all required patient information and has been obtained and charges are appropriately billed in accordance with the Organization's policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization will reinforce procedures requiring current incomeand family size documentation prior to determining sliding fee eligibility, provide additionalstaff training, and will review electronic medical record system settings to ensure properdocumentation and application of discounts. Management will conduct periodic reviews tomonitor compliance with sliding fee discount requirements. Name(s) of the contact person(s) responsible for corrective action: Chief Operations Officer or their designee. Planned completion date for corrective action plan: September 1, 2026

View Audit 407018

Finding 1223583 (2025-001)

Material Weakness 2025

Upham's Corner Health Committee, Inc.

MA

Allowable Costs / Cost Principles § 200.430

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should implement a formal time and effort reporting process that ensures payroll costs charged to federal awards are supported by contemporaneous documentation of actual work performed, requires retention of historical,...

Health Center Program – Assistance Listing No. 93.224 Recommendation: Management should implement a formal time and effort reporting process that ensures payroll costs charged to federal awards are supported by contemporaneous documentation of actual work performed, requires retention of historical, point-in-time allocation records for each payroll period (e.g., version-controlled or archived reports), and includes a documented review and approval process that compares allocation percentages to employee attestations or activity reports to validate the reasonableness and accuracy of costs charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management concurs with the finding. To address this issue, the Organization intends to fund all staff on payroll at one hundred percent of salaries and benefits to minimize the risk that allowable costs are misstated and not in compliance with 2 CFR 200.430. Name(s) of the contact person(s) responsible for corrective action: Chief Financial Officer or their designee. Planned completion date for corrective action plan: July 1, 2026

View Audit 407018

Finding 1223576 (2025-001)

Material Weakness 2025

Cowlitz Family Health Center

WA

Internal Control / Segregation of Duties Special Tests & Provisions Subrecipient Monitoring

Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended Decem...

Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Summary of finding: Testing of 40 patient encounters identified 2 instances in which the sliding fee discount schedule (SFDS) was not applied in accordance with established requirements. These instances included the incorrect application of the sliding fee scale and the failure to apply the discount when required. As a result, certain patients were undercharged or overcharged for services received. Planned corrective action: CFHC management concurs with the finding. CFHC has policies and procedures in place to ensure compliance. CFHC will provide additional training to the Patient Services Representatives and Billing Clerks to ensure the existing policies and procedures are followed. The CFHC Billing Manager will develop additional reviews to discover, correct, and educate when non-compliance is suspected. CFHC will provide targeted trainings as necessary for site level personnel. Monitoring and review will be an ongoing effort as the positions responsible for real-time compliance tend to be highly transitory. Additional review steps have already been implemented and will become part of the typical workflows to monitor compliance. Anticipated Completion Date: June 1, 2026 Contact Person: Jim Merrill, Chief Financial Officer Email: jmerrill@cfamhc.org Phone: 360-703-6701 Name and Address of Independent Public Accounting Firm: Aprio, LLP 3 Centerpointe Dr, Ste 300 Lake Oswego, OR 97035

View Audit 407001

Finding 1223574 (2025-009)

Material Weakness 2025

WIBAUX COUNTY

MT

Procurement, Suspension & Debarment Subrecipient Monitoring

NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; COMMUNITY DEVELOPMENT BLOCK GRANTS/STATES PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII, AL No. 14.228, GRANT No. MT-CDBG-21PF-14, YEAR ENDED JUNE 30, 2025 Name of contact person: County Commissioners Corrective Action: With input from the engineering fi...

NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS; COMMUNITY DEVELOPMENT BLOCK GRANTS/STATES PROGRAM AND NON-ENTITLEMENT GRANTS IN HAWAII, AL No. 14.228, GRANT No. MT-CDBG-21PF-14, YEAR ENDED JUNE 30, 2025 Name of contact person: County Commissioners Corrective Action: With input from the engineering firm, the county will develop and implement procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward. Proposed Completion Date: April 30, 2026

View Audit 407000

Finding 1223573 (2025-002)

Material Weakness 2025

Desoto Parish Police Jury

LA

Subrecipient Monitoring Allowable Costs / Cost Principles

Management will ensure that inspections are documented in each tenant file and will utilize the PHA-Web alert system to monitor any past due inspections and will conduct inspections and upload the file to the HUD PIC System. The HUD Supervisor will use the comment sections on the NSPIRE form and not...

Management will ensure that inspections are documented in each tenant file and will utilize the PHA-Web alert system to monitor any past due inspections and will conduct inspections and upload the file to the HUD PIC System. The HUD Supervisor will use the comment sections on the NSPIRE form and note any deficiencies. If there are no deficiencies, the file will state in the comment section that there are no deficiencies and reference the area’s positive outcome.

View Audit 406999

Finding 1223572 (2025-002)

Material Weakness 2025

Family Health Care of Northwest Ohio Inc.

OH

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically tes...

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026

View Audit 406997

Corrective Action Plans

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