Corrective Action Plans

Finding 1168080 (2023-004)

Material Weakness 2023

NEW YORK CITY FOUNDATION FOR COMPUTER SCIENCE EDUCATION, INC.

NY

Subrecipient Monitoring § 200.331 § 200.332

Response to finding 2023-004 – Subrecipient Monitoring Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-004. Due to the organizational pause at the end of 2024 and the transiti...

Response to finding 2023-004 – Subrecipient Monitoring Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-004. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization had limited capacity to maintain formalized subrecipient monitoring procedures aligned with 2 CFR 200.332. As CSforALL prepares for the 2026 rebuilding phase, management is establishing structured policies and procedures to ensure full compliance with federal subrecipient monitoring requirements. Corrective Action taken in 2025: During 2025, the Operations Manager ensured that all subrecipients associated with the current Alliance grant have signed or will sign formal Statements of Work with explicit deliverables and expectations required for payment. External parties without a Statement of Work are now required to submit proper documentation, invoicing, and proof of deliverables before any funds are released. No payments have been made to participants under the FY 2025 Alliance grant to date, as CSforALL is ensuring that all required policies and procedures are in place prior to both drawing down and paying out funds. Weekly and quarterly meetings have been established with external partners responsible for deliverables to confirm timelines, verify progress, and ensure alignment with payment expectations. Corrective Action Planned for 2026: Beginning in 2026, CSforALL will formalize subrecipient monitoring policies aligned with 2 CFR 200.332, including risk assessments for all subrecipients, review and documentation of Single Audit reports where applicable, issuance of management decisions, and structured ongoing monitoring activities. All monitoring documentation will be maintained in a centralized, accessible system to ensure consistent compliance throughout the 2026 operating year and beyond.

View Audit 379802

Finding 1168079 (2023-003)

Material Weakness 2023

NEW YORK CITY FOUNDATION FOR COMPUTER SCIENCE EDUCATION, INC.

NY

Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.430

Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the...

Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.

View Audit 379802

Finding 1168078 (2023-002)

Material Weakness 2023

NEW YORK CITY FOUNDATION FOR COMPUTER SCIENCE EDUCATION, INC.

NY

Procurement, Suspension & Debarment § 200.214 § 200.319 § 200.320

Response to finding 2023-002 – Procurement, Suspension, and Debarment Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-002. Due to the organizational pause at the end of 2024 a...

Response to finding 2023-002 – Procurement, Suspension, and Debarment Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-002. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization operated with significantly reduced staffing and limited capacity, which delayed the development of procurement policies addressing suspension and debarment requirements. Initial governance updates occurred during the 2025 Q4 Board meeting, where the Board approved a revised version of the By-Laws focused on correcting deficiencies in board structure and conflict-of-interest provisions. Procurement procedures recommended in this finding were not included in that initial revision but are scheduled for development and implementation as part of the 2026 rebuilding phase. Corrective Action taken in 2025: While no procurement-specific corrective action has yet been implemented, foundational updates to the By-Laws were approved at the 2025 Q4 Board meeting to address structural governance issues. These updates establish the basis for incorporating required procurement, suspension, and debarment procedures. The Operations Manager and Advisory Consultant have begun drafting updated procurement policies to ensure compliance with federal requirements. Corrective Action Planned for 2026: Draft procurement, suspension, and debarment policies will be completed and presented to the Board as a formal resolution in early 2026. Upon approval, these policies will be incorporated into the By-Laws and will take immediate effect. The Board has also approved the planned hiring of a consultant with Executive Director and strategy experience in 2026 to support policy implementation, training, staff alignment, and ongoing compliance review. These measures will ensure full compliance with procurement requirements throughout the 2026 operating year and beyond.

View Audit 379802

Finding 1168060 (2023-003)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.303

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...

Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.

View Audit 379692

Finding 1168045 (2023-002)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Cash Management Significant Deficiency § 200.303

Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...

Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024

View Audit 379692

Finding 1167998 (2023-001)

Material Weakness 2023

Marshfield Clinic Health System, Inc.

WI

Allowable Costs / Cost Principles Eligibility Reporting § 200.303

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...

Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024

View Audit 379692

Finding 1167985 (2023-004)

Material Weakness 2023

Lone Pine Paiute- Shoshone Reservation

CA

Eligibility Material Weakness Reporting § 200.329

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the award...

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the awarding agency as required. Corrective Action: The Tribe has hired a full-time bookkeeper along with a new fiscal consultant to assist the bookkeeper in journal entries, bank statements, etc. on a monthly basis. All required reporting will be done within 30 days of the end of reporting date. Anticipated date of completion: April 1, 2026.

View Audit 379637

Finding 1167984 (2023-003)

Material Weakness 2023

Lone Pine Paiute- Shoshone Reservation

CA

Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.214 § 200.303

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or d...

Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or debarred prior to entering into the contract. Corrective Action: Effective January 1, 2026, every proposal or contract that goes out will require all vendors to be active in SAMS.gov for all federal grants. This will be a requirement during the biddingprocess. Anticipated date of completion: January 30, 2026.

View Audit 379637

Finding 1167934 (2023-006)

Material Weakness 2023

County of Carbon

PA

Reporting Subrecipient Monitoring

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entit...

Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available; 21.027, COVI D-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: The tracking and matching of grant revenues and expenditures and the related grant receivable and unearned revenue amounts is necessary to assist in making management decisions and for the proper reporting and use of those funds in accordance with each of the individual grant requirements. In addition, this information is essential in preparing the County's Schedule of Expenditures of Federal Awards (SEFA}. Condition/Context: The County's system of tracking its grants and matching revenues with expenditures lacks the necessary level of sophistication, given the number and complexities of the County's grant activities, which hampers the County's ability to maintain an accurate general ledger and prepare a complete and accurate SEFA. The current year SEFA also required the restatement of beginning accrued revenue balances. Effect: Grants receivable and unearned revenue amounts are not readily ascertainable to assist in making management decisions or for use in the timely preparation of the County's SEFA. The County did not prepare a complete and accurate SEFA in a timely manner to comply with its financial reporting requirements. Cause: The County has not prioritized a formal system for tracking its grant activities. Recommendation: We recommend that the County develop and implement a formal system for tracking its grant related activities and in doing so require that all departments with responsibility for federal award programs provide periodic reconciliations of their grant reports to the general ledger to a responsible management official. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the restatement of the beginning accrued revenue balances on the SEFA and is working to realign staff responsibilities to provide a dedicated business office staff member to oversee, track, report and manage all of the County's grant awards. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026

View Audit 379448

Finding 1167925 (2023-005)

Material Weakness 2023

County of Carbon

PA

Student Financial Aid Subrecipient Monitoring Reporting

Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity...

Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2022 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2022 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the County hopes to have cleared by the 2025 audit. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026

View Audit 379448

Finding 1167814 (2023-003)

Material Weakness 2023

Pohnpei Utilities Corporation

FM

Special Tests & Provisions HUD Housing Programs Reporting

PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO

View Audit 379154

Finding 1167797 (2023-001)

Material Weakness 2023

Hearth Homes of Waterbury, INC

CT

Cash Management HUD Housing Programs

U.S. Department of Housing & Urban Development 20 Church Street, 10th floor Hartford, CT 06103 Elderly Housing Management, Inc. respectfully submits the following corrective action plan for Hearth Homes of Waterbury, Inc. (HUD PROJECT NO. Ol 7-EE108) year ended June 30, 2023, which was audited by: B...

U.S. Department of Housing & Urban Development 20 Church Street, 10th floor Hartford, CT 06103 Elderly Housing Management, Inc. respectfully submits the following corrective action plan for Hearth Homes of Waterbury, Inc. (HUD PROJECT NO. Ol 7-EE108) year ended June 30, 2023, which was audited by: Bailey, Moore, Glazer, Shaefer & Proto LLP 16 Lunar Drive Woodbridge, CT 06525 The sole finding from the 6/30/2023 schedule of findings and questions costs is discussed below and numbered consistently with the numbers assigned in the schedule. FINDINGS- FINANCIAL STATEMENT AUDIT NONE FINDINGS - FEDERAL AW ARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Finding number 2023-001: 14.157 Supportive Housing for the Elderly Condition: The Project requested and received approval for reimbursement of the same invoice twice. Recommendation: Funds totaling $4,134 be returned to the replacement reserves as soon as possible. Action Taken: On November 25, 2025, a check in the amount of $4,134.00 was cut from the operating account. The funds have subsequently been returned to the replacement reserve account. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sabine Cox at (203-230-4809 ext. I 005)

View Audit 379091

Finding 1167725 (2023-010)

Material Weakness 2023

Defensewerx

FL

Reporting Internal Control / Segregation of Duties § 200.302 § 200.328

We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be ...

We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be easily reconciled to the underlying accounting records.

View Audit 378959

Finding 1167724 (2023-009)

Material Weakness 2023

Defensewerx

FL

Allowable Costs / Cost Principles § 200.403 § 200.430

As noted above, we are working with consultants and our government partners to determine and define the requirements for each relevant program. We understand the recommendations offered and will review, and possibly revise, our policies and procedures, including supervisory review of documentation t...

As noted above, we are working with consultants and our government partners to determine and define the requirements for each relevant program. We understand the recommendations offered and will review, and possibly revise, our policies and procedures, including supervisory review of documentation to support the allowability of costs charged to federal agreements. We will also review existing policies and procedures for preventing or detecting and correcting unallowable costs charged to federal agreements to ensure consistent application of those policies and procedures for all costs charged to federal agreements.

View Audit 378959

Finding 1167723 (2023-008)

Material Weakness 2023

Defensewerx

FL

Procurement, Suspension & Debarment § 200.403 § 200.412

As noted above, we are working with consultants and our government partners to understand the requirements for each relevant program. We understand the recommendations offered and are exploring a comprehensive indirect cost allocation policy that would align with applicable requirements.

View Audit 378959

Finding 1167722 (2023-007)

Material Weakness 2023

Defensewerx

FL

Special Tests & Provisions Matching / Level of Effort / Earmarking

We agree with the recommendations offered for the relevant programs and will establish updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel.

View Audit 378959

Finding 1167721 (2023-006)

Material Weakness 2023

Defensewerx

FL

Procurement, Suspension & Debarment

We agree with the recommendations offered and will establish more formal policies and procedures and build workflows and approvals into Costpoint to address the findings while considering appropriate segregation of duties.

View Audit 378959

Finding 1167720 (2023-005)

Material Weakness 2023

Defensewerx

FL

Equipment & Real Property Management

We agree with the recommendations offered for the relevant programs and will establish updated policies and procedures to address the findings while considering appropriate measures and tools to ensure compliance by the various locations.

View Audit 378959

Finding 1167719 (2023-004)

Material Weakness 2023

Defensewerx

FL

Cash Management

We agree with the recommendations offered and at the time of this report have established updated policies and procedures to address the finding while considering appropriate measures for operating programs that our government partners require to be on a cost reimbursement basis. We have addressed t...

We agree with the recommendations offered and at the time of this report have established updated policies and procedures to address the finding while considering appropriate measures for operating programs that our government partners require to be on a cost reimbursement basis. We have addressed this finding to our government partners. The majority of our government partners fund in monthly or quarterly increments. Periodically we update our government partners on program funds that have been used or those funds that are excess.

View Audit 378959

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Finding type: Significant deficiency.

View Audit 378742

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Federal award: 93.912, Rural Health Care Services Outreach.

View Audit 378742

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Passthrough organization: Not applicable.

View Audit 378742

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Condition: Lack of approval on bank reconciliations and journal entries.

View Audit 378742

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Management concurrence: Management concurs with this finding.

View Audit 378742

Finding 1167585 (2023-005)

Material Weakness 2023

Vermont Association for Mental Health and Addiction Recovery, INC

VT

Internal Control / Segregation of Duties

Corrective action plan: VAMHAR has put internal controls and a process in place for approvals of journal entries reconciliations as of fiscal year 2024.

View Audit 378742

Corrective Action Plans

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