Corrective Action Plans

Finding 1167968 (2024-002)

Material Weakness 2024

MT

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

Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with th...

Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. MCC has updated the Financial Process Procedure to include language related to receipt management, and allowable and disallowed grant expenses. MCC has created a Travel Reimbursement Procedure that addresses approval of Director expenses. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators

View Audit 379617

Finding 1167967 (2024-001)

Material Weakness 2024

Montana Cancer Consortium

MT

Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking § 200.302 § 200.305 § 200.313 § 200.430

Finding 2024-001: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.399 – Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require co...

Finding 2024-001: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.399 – Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. Montana Cancer Consortium (MCC) has updated the Financial Process Procedure to include language related to receipt management, allowable and disallowed grant expenses, and timing of payment requests. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators

View Audit 379617

Finding 1167962 (2024-001)

Material Weakness 2024

Birmingham Jefferson County Transit Authority

AL

Reporting Significant Deficiency § 200.512

Clearinghouse (Significant Deficiency and Noncompliance)-(Repeat Finding) Condition: The Authority failed to timely submit the collection form or audit reporting package to the Federal Audit Clearinghouse for the period ending September 30, 2024. Views of Responsible Officials and Planned Corrective...

Clearinghouse (Significant Deficiency and Noncompliance)-(Repeat Finding) Condition: The Authority failed to timely submit the collection form or audit reporting package to the Federal Audit Clearinghouse for the period ending September 30, 2024. Views of Responsible Officials and Planned Corrective Actions: In 2024, the Authority continued to face challenges with staffing shortages and turnover in key financial positions. These challenges resulted in delays in performing and completing accounting functions and issuing financial statements in a timely manner. However, the Finance Department now has both a Controller and Accounting Supervisor and these positions should provide talent and experience to ensure accounting functions and processes are performed and completed in a timely matter. Moreover, processes are now in place to ensure accounting procedures are performed timely and those processes require signoff for reviews by top Accounting and Finance officials. Our personnel and process enhancements will enable the Authority to submit the reporting package to the Federal Audit Clearinghouse by the prescribed due date. Contact Person Responsible for Corrective Action: Glenn Dickerson, CPA — Chief Financial Officer Anticipated Completion Date: October 2025

View Audit 379584

Finding 1167912 (2024-001)

Material Weakness 2024

Liberate Medical, Inc.

KY

Subrecipient Monitoring

Section III - Federal Award Findings and Questioned Costs: U.S. Department of Defense Recommendation: Appropriate written subrecipient monitoring policies and procedures be developed and implemented, including a schedule for various financial reviews to document that subrecipients are complying with...

Section III - Federal Award Findings and Questioned Costs: U.S. Department of Defense Recommendation: Appropriate written subrecipient monitoring policies and procedures be developed and implemented, including a schedule for various financial reviews to document that subrecipients are complying with the Federal regulations and with the terms and conditions of the subaward. Management has taken the following actions with regards to the current finding. • The five subrecipients are as follows: o Chicago Association for Research and Education o Houston Methodist Research Institute o Tufts Medical Center, Inc. o University of Pittsburgh o Vanderbilt University • Verified that all subrecipients are audited and that none are suspended, debarred, or otherwise excluded from receiving Federal Funds. • Obtained most recent Single Audit Report from each subrecipient and determined that there were no audit findings related to the Company. The following was identfied in each audit report: o Chicago Association for Research and Education – Year Ended September 30, 2024 - The Company is not listed in the Single Audit Report – Management is following up with the institution. o Houston Methodist Research Institute - Year Ended December 31, 2023 - Military Medical Research and Development through Liberate Medical, LLC - W81XWH2211123 - 12.420 - $11,107 o Tufts Medical Center, Inc. - Year Ended September 30, 2023 - Military Medical Research and Development Passed Through—Liberate Medical LLC—A Randomized, Sham Controlled, Double-blinded, MulM-center Trial to Evaluate the Efficacy of the VentFree Respiratory Muscle Stmulator to Assist Ventilator Weaning in Critically III Patients - 12.420 - W81XWH2211123 - $14,770 o University of Pittsburgh - Year Ended June 30, 2024 - Liberate Medical, LLC. - 12.420 - PREVENT-LIBERATE – Planning Phase $1,415; Trial Phase $84,087 o Vanderbilt University - Year Ended June 30, 2024 - MILITARY MEDICAL RESEARCH AND DEVELOPMENT - 12.420 - Liberate Medical VUMC108554 -W81XWH2211123 $52,147 • Management is reviewing costs included in the subrecipient’s Single Audit Report noted above and working with the subrecipients to reconcile amounts to the Company’s books and records. For the year ended December 31, 2024, the Company submitted reimbursement voucher requests to the Department of Defense in the amount of $1,766,172. Amounts related to subawards for the same period were $134,695 or 7.6%. In the future management will: • Prepare a standard operating procedure (SOP) for subrecipient monitoring in accordance with CFR Part 200.332 and OMB Compliance Supplement 6-20. • For the current award: o Evaluate each subrecipient’s fraud risk and risk of noncompliance o Develop a subrecipient risk-based monitoring plan sufficient for the Company to comply with federal statues, regulations, and the terms and conditions of the award. o Follow the developed risk-based monitoring plan for the remainder of the award and implement, where appropriate, corrective actions against any noncompliant subrecipients • For future awards, perform subrecipient monitoring in accordance with the SOP described above and in compliance with CFR Part 200.332 and OMB Compliance Supplement 6-20.

View Audit 379429

Finding 1167911 (2024-004)

Material Weakness 2024

Kansas Grazing Lands Coalition, Inc.

KS

Procurement, Suspension & Debarment § 200.517

Views of Responsible Officials (unaudited): The Organization will develop a procurement and payment procedure to ensure all proper supporting documentation is obtained prior to the check disbursement.

View Audit 379422

Finding 1167910 (2024-003)

Material Weakness 2024

Kansas Grazing Lands Coalition, Inc.

KS

Procurement, Suspension & Debarment § 200.213

Views of Responsible Officials (unaudited): The Organization agrees with the finding and recommendation. The Board of Directors of the Organization will develop policies and procedures to ensure they meet the Uniform Guidance Requirements.

View Audit 379422

Finding 1167909 (2024-002)

Material Weakness 2024

Kansas Grazing Lands Coalition, Inc.

KS

Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.319

Views of Responsible Officials (unaudited): The Organization agrees with the finding and recommendation. The Board of Directors of the Organization will develop policies and procedures to ensure they meet the Uniform Guidance Requirements.

View Audit 379422

Finding 1167903 (2024-005)

Material Weakness 2024

City of Seadrift Texas

TX

Cash Management

Staff Training: Provide training for multiple City staff on reviewing, interpreting, and administering grant contracts to ensure compliance with all requirements. Policies and Procedures: Develop and maintain written policies and procedures for grant management to promote consistency and accountabil...

Staff Training: Provide training for multiple City staff on reviewing, interpreting, and administering grant contracts to ensure compliance with all requirements. Policies and Procedures: Develop and maintain written policies and procedures for grant management to promote consistency and accountability across all projects. Oversight of Third-Party Administrators: Implement additional review processes to ensure accuracy and compliance in work performed by third-party grant administrators. Documentation of Roles: Clearly document roles and responsibilities between the City and third-party contractors to ensure all tasks and obligations are fully covered.

View Audit 379376

Finding 1167875 (2024-002)

Material Weakness 2024

Central Illinois Agency on Aging

IL

Internal Control / Segregation of Duties Material Weakness

There is no disagreement with the audit finding. Management has subsequently engaged a payroll service provider and an outsourced accountant to improve internal controls.

View Audit 379262

Finding 1167845 (2024-001)

Material Weakness 2024

M.c. Preparatory School of Wisconsin, Inc.

WI

Allowable Costs / Cost Principles Cash Management Period of Performance

CORRECTIVE ACTION PLAN April 10, 2025 M.C. College Preparatory School of Wisconsin, Inc., respectfully submits the following corrective action plan for the year ending June 30, 2024. Walkowicz, Boczkiewicz & Co., S.C. 1800 East Main Street, Suite 100 Waukesha, WI 53186 AUDIT PERIOD: June 30, 2024 Th...

CORRECTIVE ACTION PLAN April 10, 2025 M.C. College Preparatory School of Wisconsin, Inc., respectfully submits the following corrective action plan for the year ending June 30, 2024. Walkowicz, Boczkiewicz & Co., S.C. 1800 East Main Street, Suite 100 Waukesha, WI 53186 AUDIT PERIOD: June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION MATERIAL WEAKNESS 2024-001 Elementary and Secondary School Emergency Relief Fund - COVID-19 – CFDA No. 84.425 Condition: During the audit of submitted claims, it was found that there was a lack of sufficient review procedures to ensure proper verification of costs. Specifically, several instances of duplicated expenditures were identified within the claims. The same costs were submitted more than once for reimbursement, resulting in questioned costs. Criteria: The Organization's internal controls should require that claims be thoroughly reviewed for accuracy and completeness before submission. This includes verifying that costs are not duplicated and ensuring proper documentation supports each expenditure. Additionally, the previously submitted claims included in the period of performance should be monitored to prevent duplication. Cause: The review process did not involve cross-checking with previous claims or documentation to identify and prevent the submission of duplicate costs. Effect: As a result of inadequate claim reviews, the organization has submitted claims containing duplicated costs. These duplicated expenditures have resulted in questioned costs, which may need to be refunded. The failure to detect and prevent such errors could lead to non-compliance with funding requirements. Questioned costs: $505,820 Auditor’s recommendation: It is recommended that the organization implement a more thorough review process for all submitted claims. This should include cross-checking current claims against previous claims to detect and prevent duplicated costs. A system should be implemented to track claims and associated costs more effectively, ensuring that no expenditure is claimed more than once. Action Taken: M.C. College Preparatory School of Wisconsin, Inc.’s Management has completed the transition to a new payroll system with enhanced process controls as of December 2024. This system enables the organization to isolate funding source allocations at the individual employee level, thereby preventing expenses from being attributed to more than one source. Final programming and control reviews are scheduled for completion prior to June 30, 2025. Further, Management has reviewed the questioned costs with the local education authority and has submitted qualified replacement expenses for all amounts initially submitted in error. As a result, no refund is required, and the applicable financial reserve will be released in the upcoming fiscal year. If the Department of Education has questions regarding this plan, please call Alfred Keith IV at 414-264-6000. Sincerely yours, Alfred Keith IV Chief Education Officer

View Audit 379189

Finding 1167844 (2024-004)

Material Weakness 2024

Columbia Opportunities, Inc.

NY

Reporting

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-004 Corrective Action Plan The Organization acknowledges a...

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-004 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management and fiscal departments are responsible for timely reporting. Management will follow its comprehensive policies and procedures and complete reporting submissions on time for future periods.

View Audit 379176

Finding 1167843 (2024-003)

Material Weakness 2024

Columbia Opportunities, Inc.

NY

Reporting

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-003 Corrective Action Plan The Organization acknowledges a...

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-003 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management and fiscal departments are responsible for timely reporting. Management will follow its comprehensive policies and procedures and complete reporting submissions on time for future periods.

View Audit 379176

Finding 1167842 (2024-002)

Material Weakness 2024

Columbia Opportunities, Inc.

NY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.512

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-002 Corrective Action Plan The Organization acknowledges a...

Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2023 - October 31, 2024 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2024-002 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management and fiscal departments are responsible for timely reporting. Management will follow its comprehensive policies and procedures and complete reporting submissions on time for future periods.

View Audit 379176

Finding 1167831 (2024-001)

Material Weakness 2024

County of Mariposa

CA

Reporting

2024-001 Highway Planning and Construction; Coronavirus State and Local Fiscal Recovery Funds; Local Assistance and Tribal Consistency Fund. We recommend that the County Departments provide the County Auditor with accurate federal expenditure information prior to the beginning of audit fieldwork. Ma...

2024-001 Highway Planning and Construction; Coronavirus State and Local Fiscal Recovery Funds; Local Assistance and Tribal Consistency Fund. We recommend that the County Departments provide the County Auditor with accurate federal expenditure information prior to the beginning of audit fieldwork. Management's Response: The County concurs with the finding. Responsible Individual: Luis Mercado, Auditor. Corrective Action Plan: The Auditor's Office will work with County departments to ensure federal expenditure information is accurate. Anticipated Completion Date: Fiscal Year 2024-2025.

View Audit 379163

Finding 1167796 (2024-005)

Material Weakness 2024

Village of Whitehouse

OH

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will se...

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will seek out training on federal procurement compliance requirements.

View Audit 379090

Finding 1167795 (2024-004)

Material Weakness 2024

Village of Whitehouse

OH

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will se...

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will seek out training on federal procurement compliance requirements.

View Audit 379090

Finding 1167794 (2024-003)

Material Weakness 2024

Village of Whitehouse

OH

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.318

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will se...

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will seek out training on federal procurement compliance requirements.

View Audit 379090

Finding 1167793 (2024-002)

Material Weakness 2024

Village of Whitehouse

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will se...

The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will seek out training on federal procurement compliance requirements.

View Audit 379090

Finding 1167765 (2024-004)

Material Weakness 2024

Village of Lyndon Station

WI

Procurement, Suspension & Debarment

Procurement and Suspension and Debarment Policy Deficiencies Federal Agency: U.S. Department of Agriculture Federal Program: Water and Waste Facility Loans and Grants to Alleviate Health Risks, Assistance Listing Number 10.770 Award Period: August 24, 2022 through August 24, 2025 Recommendation: The...

Procurement and Suspension and Debarment Policy Deficiencies Federal Agency: U.S. Department of Agriculture Federal Program: Water and Waste Facility Loans and Grants to Alleviate Health Risks, Assistance Listing Number 10.770 Award Period: August 24, 2022 through August 24, 2025 Recommendation: The Village should continue to evaluate its policies to ensure they are in accordance with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The Village continues to work at updating its policy and procedures manuals. The Village will amend policies as necessary. Name(s) of the contact person(s) responsible for corrective action: Michelle Klein, Village Clerk-Treasurer. Planned completion date for corrective action plan: The Village will adopt procurement and suspension and debarment policies in accordance with Uniform Guidance by December 31, 2025.

View Audit 379046

Finding 1167741 (2024-003)

Material Weakness 2024

Huerfano School District No. Re-1

CO

Cash Management Internal Control / Segregation of Duties

The contract accounting team provides a team which includes a Business Manager and support staff and we maintain reimbursement records and detailed general ledger, banking, and invoice records in an external drive so that the archives are available for further reconciliation and internal or external...

The contract accounting team provides a team which includes a Business Manager and support staff and we maintain reimbursement records and detailed general ledger, banking, and invoice records in an external drive so that the archives are available for further reconciliation and internal or external audit.

View Audit 378983

Finding 1167654 (2024-101)

Material Weakness 2024

Booker T. Washington Child Development Center, Inc.

AZ

Reporting Significant Deficiency Internal Control / Segregation of Duties

Person Responsible: Josie Ayon Estimated Completion Date: 3/31/2026 Planned Corrective Action: The organization converted from the Cash Basis of Accounting to the Accrual Basis of Accounting (GAAP) in fiscal year 2023. Additionally, the organization converted to a new accounting system and hired out...

Person Responsible: Josie Ayon Estimated Completion Date: 3/31/2026 Planned Corrective Action: The organization converted from the Cash Basis of Accounting to the Accrual Basis of Accounting (GAAP) in fiscal year 2023. Additionally, the organization converted to a new accounting system and hired outside consultants to assist with data entry and financial reporting. The audit for June 30, 2025 is planned to start in December 2025, which will provide adequate time to comply with this requirement.

View Audit 378906

Finding 1167653 (2024-001)

Material Weakness 2024

Montgomery Community and Community Development Corporation, Inc. and Subsidiaries

FL

Allowable Costs / Cost Principles

Management is in the process of implementing policies and procedures to ensure cost incurred for the delivery of meals to children are allowable and reasonable.

View Audit 378897

Finding 1167595 (2024-001)

Material Weakness 2024

City of North Chicago

IL

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024 – 001: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Corrective Action Plan: The Comptroller, along with staff, will review year-end adjustments as part of the ...

Finding 2024 – 001: Audit Journal Entries Condition: During audit fieldwork, our testing resulted in significant audit adjustments in order to present materially accurate financial statements. Corrective Action Plan: The Comptroller, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2025 Name of Contact Person: Tawanda Joyner, Comptroller Management Response: The Comptroller, with staff, will review year-end adjustments as part of audit preparation, aiming to reduce auditor-proposed entries and to deliver an adjusted trial balance before fieldwork. City was short staffed however, currently have a full staff to be able to complete journal entries. Our actions to correct include an internal review of year-end adjustments to identify causes and implement fixes, along with the use of pre-audit checklists and earlyanalytics to minimize auditor entries. Our team will finalize adjustments well ahead of fieldwork.At the start of the audit, the fully adjusted financial statements will be submitted and inquiries addressed. Our target is a 70% reduction in auditor-proposed entries and for adjustments resolved pre-fieldwork. The plan also calls for documenting any delays with the team responding to auditor inquiries within 24 hours and for misclassifications to be reviewed by two staff members to ensure accuracy.

View Audit 378791

Finding 1167569 (2024-002)

Material Weakness 2024

City of Greeley

CO

Reporting § 200.502 § 200.510

Condition: The CDBG Cluster and Federal Transit Cluster expenditures on the schedule of expenditures of federal awards (SEFA) initially presented for audit were not complete and accurate. Planned Corrective Action: Due to turn-over and the loss of a long-term employee new processes were implemented ...

Condition: The CDBG Cluster and Federal Transit Cluster expenditures on the schedule of expenditures of federal awards (SEFA) initially presented for audit were not complete and accurate. Planned Corrective Action: Due to turn-over and the loss of a long-term employee new processes were implemented to prepare reporting and documentation processes for the Federal Transit Cluster. Written Standard Operating Procedures have been generated and will be updated as necessary. Reporting and draw processes have been updated to include written signatures of approval for the documentation. The staff in transit and finance work closely together to ensure the completeness of records. City of Greeley will also be organizing a formalized grants team that will be dedicated to all grant activities including the SEFA and correcting the prior staffing insufficiencies. Contact person responsible for corrective action: Rebecca Romero, Grant Accountant Anticipated Completion Date: 03/01/2026

View Audit 378666

Finding 1167553 (2024-001)

Material Weakness 2024

City of Dublin, Georgia

GA

Procurement, Suspension & Debarment

Management will implement a process to ensure all vendors are verified for suspension and debarment prior to awarding or extending a contract. The process will be documented in the vendor file.

View Audit 378631

Corrective Action Plans

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