Corrective Action Plans

Finding 1218362 (2024-002)

Material Weakness 2024

Community Renewal Team, Inc. and Affiliates

CT

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency

CRT will initiate an outreach plan for low-income representation to fill the open positions on the Board. The President and Chief Executive Officer or designee will solicit Low-Income Director nominations from organizations and groups within the agency or the community that are recognized as serving...

CRT will initiate an outreach plan for low-income representation to fill the open positions on the Board. The President and Chief Executive Officer or designee will solicit Low-Income Director nominations from organizations and groups within the agency or the community that are recognized as serving or representing low-income residents following federal regulations, State statutes, CRT By-Laws and agency approved Democratic Selection Procedures. Upon review of the qualifications of the nominated candidates by the CRT Nominating Subcomittee, they will vote to select the best qualified candidate(s) for appointment to the Board. After the candidate(s) have been determined by the Nominating Subcommitee to meet the qualifications, the Board will vote whether to elect the proposed individual to the Board.

View Audit 404643

Finding 1218165 (2024-002)

Material Weakness 2024

Taller Educativo De Caguas, Inc.

PR

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Management has implemented a formal procedure to ensure that future Single Audits are completed and submitted within the required timeframe. This procedure includes the following actions: First Quarter (January – March): The Purchasing Unit will initiate the procurement process for the independent a...

Management has implemented a formal procedure to ensure that future Single Audits are completed and submitted within the required timeframe. This procedure includes the following actions: First Quarter (January – March): The Purchasing Unit will initiate the procurement process for the independent auditors, in coordination with the Fiscal Manager, while year-end closing activities are being completed, to ensure timely engagement of audit services. Second Quarter (April – June): Once the auditor is engaged, the program will initiate the audit engagement and provide the required documentation in accordance with the established audit schedule.

View Audit 404355

Finding 1218092 (2024-002)

Material Weakness 2024

Renaissance Social Services, Inc.

IL

Internal Control / Segregation of Duties

Management concurs with the findings. During the fiscal year, turnover in key finance leadership positions impacted on the continuity of accounting operations and reduced the effectiveness of established financial close and reconciliation processes. • Strengthened financial leadership and oversight ...

Management concurs with the findings. During the fiscal year, turnover in key finance leadership positions impacted on the continuity of accounting operations and reduced the effectiveness of established financial close and reconciliation processes. • Strengthened financial leadership and oversight by elevating the lead finance position to a Chief Financial Officer role and recruiting a highly qualified finance executive. • Filled critical finance and accounting positions to enhance internal controls, improve accountability, and ensure adequate operational oversight. • Documenting and formalizing month-end and year-end close procedures, including detailed reconciliation requirements and review responsibilities. • Implementing standardized account reconciliation templates and review sign-off procedures for all significant balance sheet accounts. • Cross-training accounting personnel and maintaining written process documentation to reduce operational risks associated with staff turnover.

View Audit 404272

Finding 1218082 (2024-005)

Material Weakness 2024

CITY OF ADAMS

WI

Cash Management Subrecipient Monitoring Reporting

Finding #2024-005 – Lack of Written Grant Procedures over Federal Programs Criteria: Under Federal Uniform Guidance, all non-Federal subrecipient entities must establish and maintain written policies and procedures over Federal programs. Written grant procedures are required in the areas of verifyin...

Finding #2024-005 – Lack of Written Grant Procedures over Federal Programs Criteria: Under Federal Uniform Guidance, all non-Federal subrecipient entities must establish and maintain written policies and procedures over Federal programs. Written grant procedures are required in the areas of verifying allowable costs, cash management, and conflicts of interest, while procurement, subrecipient monitoring, and reporting procedures should also be included. Condition: During their audit procedures, the auditors noted that the City did not have comprehensive written grant procedures governing key compliance areas. Cause: The City’s management has relied on informal practices and institutional knowledge rather than formulating a grant procedures manual. Effect: Without written procedures, there is an increased risk of noncompliance with Uniform Guidance, including improper cost charging, non-compliant procurement, untimely drawdowns or cash on hand, inadequate subrecipient oversight, and ineffective internal controls. This exposes the City to the risk of questioned costs, potential repayment of federal funds, audit findings, and other possible impacts. Recommendation: The auditors recommend that the City develop, approve, and implement a consolidated Federal grant procedures manual. The procedures should not be a replication of the Federal requirements but instead step-by-step processes that are necessary to be in compliance with the Federal guidelines. Response: The City will begin the process of drafting and approving a Federal grant procedures manual in order to be in compliance with Federal requirements going forward.

View Audit 404246

Finding 1218081 (2024-001)

Material Weakness 2024

CITY OF ADAMS

WI

Internal Control / Segregation of Duties

Finding #2024-001 – Material Audit Adjustments Criteria: Proper financial closing and year-end reconciliation procedures should be in place to identify and adjust the financial records to ensure the financial statements are fairly stated. Condition: The auditors proposed audit adjustments that, if n...

Finding #2024-001 – Material Audit Adjustments Criteria: Proper financial closing and year-end reconciliation procedures should be in place to identify and adjust the financial records to ensure the financial statements are fairly stated. Condition: The auditors proposed audit adjustments that, if not made, would have resulted in the financial statements being materially misstated. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Effect: The City’s system of internal control may not prevent, detect, or correct misstatements in the financial statements. Financial reports generated by the accounting system may not provide an accurate reflection of the City’s financial position or activities. Not reconciling accounts on a timely basis could lead to errors or other problems not being recognized and resolved. Recommendation: The auditors recommend that policies and procedures should be implemented to ensure account balances are properly recorded and reconciled in a timely manner. Response: The City acknowledges their responsibility for the financial statements and recording of the current year activity. Going forward, the City will work toward verifying that all activity is completely and accurately recorded in the financial records and reflected on the financial statements.

View Audit 404246

Finding 1218063 (2024-004)

Material Weakness 2024

Community Health Service, Inc.

MN

Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness

Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Ensure complete documentation is obtained and retained. - Implement monitoring and periodic reviews. - Provide staff training. Responsible Parties: Chief Executive Officer and Chief Financial Officer

View Audit 404217

Finding 1218062 (2024-003)

Material Weakness 2024

Community Health Service, Inc.

MN

Cash Management Internal Control / Segregation of Duties Material Weakness § 200.305

Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and Chief Financial ...

Type: Material Weakness in Internal Control Over Compliance Corrective Actions: - Implement reconciliation of each drawdown to actual expenditures. - Require detailed supporting documentation. - Establish supervisory approval process. Responsible Parties: Chief Executive Officer and Chief Financial Officer

View Audit 404217

Finding 1218030 (2024-004)

Material Weakness 2024

Papa Ola Lokahi

HI

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.512 § 200.514

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a del...

Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2023-004) and current year renumbered recommendation (2024-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) continue to challenge the Organization, however, the Organization notes the status and progress of the following single audits: • June 30, 2022, filed in the Federal Audit Clearinghouse (FAC) in February 2025. • June 30, 2023, filed in the FAC in March 2026. • June 30, 2024, final review by Board in progress, projected filing in the FAC in June 2026. • June 30, 2025, engagement field work in progress with projected filing date no later than September 2026. • June 30, 2026, engagement letter signed with scheduled field work to commence after the June 30, 2025, audit FAC filing; projected to be completed with related FAC filing, no later than March 2027. The Organization notes the corrective actions that have been implemented, regarding internal controls to ensure compliance with the Uniform Guidance with respect to the submission deadline of single audit reports and the Data Collection Form: A. Internal Controls in Practice Since Inception of New Auditor Engagement – April 2023. As noted in the prior year corrective action response, the Organization established internal compliance controls related to the timely submission of single audit reports. Such process and review controls are implemented by the director of administrative operations, chief of staff (since December 2024), and chief executive officer; and subsequently communicated to the Board finance sub-committee and full Board, including the documented Board action(s) taken (e.g., Board agenda, minutes). B. Financial Policies and Procedures – May 2025. By May 2025, the Organization completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. Note the internal control policy of the Organization documents process and review controls, which were already in practice, applying to the timely filing of single audit reports. The current practices of the Organization, to the present period of the report dated June 17, 2026 is consistent with established process and review controls for timely submission of single audit reports.

View Audit 404207

Finding 1217939 (2024-003)

Material Weakness 2024

St. Luke's Hospital

ND

Special Tests & Provisions Material Weakness Matching / Level of Effort / Earmarking § 200.303

Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although ...

Federal Agency Name: Department of Agriculture Assistance Listing Number: 10.766 Program Name: Community Facilities Loans and Grants Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure the proper disbursement and funding of the reserve account. Although management obtained a waiver for the noncompliance, the lack of adequate policies governing proper funding of reserve increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Corrective Action Plan: Management will review and enhance internal control policies to ensure that there is proper funding of the reserve accounts. Responsible Individuals: Jody Nelson, CEO and Megan Peterson, CFO

View Audit 404103

Finding 1217887 (2024-001)

Material Weakness 2024

Philadelphia Housing Development Corporation

PA

Reporting Internal Control / Segregation of Duties

Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026

View Audit 403972

Finding 1217814 (2024-001)

Material Weakness 2024

Philadelphia Housing Development Corporation

PA

Reporting Internal Control / Segregation of Duties

Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026

View Audit 403923

Finding 1217743 (2024-003)

Material Weakness 2024

Boys & Girls Clubs of Southcentral Alaska

AK

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303 § 200.400

The Boys and Girls Clubs of Southcentral Alaska has contracted with a national accounting firm, Fohrman and Fohrman, to reconcile the 2025 books and implement a simpler accounting structure. There will still be significant findings in 2025 as the organization ultimately closed due to financial insta...

The Boys and Girls Clubs of Southcentral Alaska has contracted with a national accounting firm, Fohrman and Fohrman, to reconcile the 2025 books and implement a simpler accounting structure. There will still be significant findings in 2025 as the organization ultimately closed due to financial instability. The new system will be implemented in 2026. Fohrman and Fohrman will continue on contract to ensure adequate grant reporting and compliance with reporting requirements.

View Audit 403865

Finding 1217623 (2024-002)

Material Weakness 2024

Aids Services Coalition

MS

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.507

management has taken the following actions: Defined Roles and Responsibilities: A primary audit coordinator will be designated to oversee all audit-related requests. Clear ownership has been assigned to appropriate personnel for each audit area to ensure accountability for timely responses.  Formal...

management has taken the following actions: Defined Roles and Responsibilities: A primary audit coordinator will be designated to oversee all audit-related requests. Clear ownership has been assigned to appropriate personnel for each audit area to ensure accountability for timely responses.  Formal Review Procedures: All audit support will undergo a supervisory review prior to submission to ensure completeness, accuracy, and appropriateness of documentation.  Enhanced Oversight: Management will conduct periodic status meetings during the audit process to monitor progress, resolve bottlenecks, and ensure deadlines are met.  Training and Communication: Accounting and relevant personnel will receive additional guidance regarding audit expectations, timelines, and documentation standards to improve overall responsiveness and quality.

View Audit 403795

Finding 1217535 (2024-002)

Material Weakness 2024

County of Norfolk

MA

Reporting Internal Control / Segregation of Duties

The County of Norfolk, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024 Name and address of the independent public accounting firm: CBIZ CPA’s 53 State Street, 17th Floor Boston, MA 02109 Audit Periods: July 1, 2023 through June 30, 2024 2024-0...

The County of Norfolk, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024 Name and address of the independent public accounting firm: CBIZ CPA’s 53 State Street, 17th Floor Boston, MA 02109 Audit Periods: July 1, 2023 through June 30, 2024 2024-002: Other Matters – Filing in Accordance with OMB Guidance Criteria or Specific Requirement: OMB guidelines require the Single Audit to be completed and submitted to the Federal Audit Clearinghouse no later than nine months after fiscal year end. Condition: The failure to reconcile accounts promptly has resulted in delays in the completion of the County’s financial statement audits and single audit filings over multiple years. Cause: The County lacks effective internal controls and established procedures to ensure timely and accurate reconciliation of accounts, which has hindered the audit process and led to delays in meeting Single Audit reporting deadlines. Effect: The County is not in compliance with the OMB guidelines. Recommendation: We recommend that County management develop and implement formal policies and procedures to ensure timely account reconciliations and accurate financial reporting. These procedures should specifically address the requirements for the timely completion and submission of the Single Audit, in accordance with OMB guidelines. Views of Responsible Officials and Planned Corrective Actions: The factors contributing to the delays in financial reporting have been resolved and the county plans on being in full compliance for the SEFA reporting by fiscal year 2026. If the Oversight Agency has questions regarding this plan, please call John Cronin at (781) 234-3435. Sincerely yours, John Cronin

View Audit 403687

Finding 1217476 (2024-002)

Material Weakness 2024

Saunders County

NE

Reporting Internal Control / Segregation of Duties

The County recognizes the deficiencies in their internal control related to segretation of duties and preparation of the financial statements. They will continue to update, implement, and monitor their financial procedures, and implement mitigating controls as much as possible. In view of cost consi...

The County recognizes the deficiencies in their internal control related to segretation of duties and preparation of the financial statements. They will continue to update, implement, and monitor their financial procedures, and implement mitigating controls as much as possible. In view of cost considerations, adding personnel to address these deficiencies would not be practical.

View Audit 403649

Finding 1217475 (2024-001)

Material Weakness 2024

Saunders County

NE

Internal Control / Segregation of Duties

The County recognizes the deficiencies in their internal control related to segretation of duties and preparation of the financial statements. They will continue to update, implement, and monitor their financial procedures, and implement mitigating controls as much as possible. In view of cost consi...

The County recognizes the deficiencies in their internal control related to segretation of duties and preparation of the financial statements. They will continue to update, implement, and monitor their financial procedures, and implement mitigating controls as much as possible. In view of cost considerations, adding personnel to address these deficiencies would not be practical.

View Audit 403649

Finding 1217427 (2024-004)

Material Weakness 2024

Baltimore Corps, INC

DC

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.512

Schedule of Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004: Significant Deficiency in internal Controls and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the findings. We acknowledge the importance of adhering to the ...

Schedule of Corrective Action Plan For the Year Ended June 30, 2024 Finding 2024-004: Significant Deficiency in internal Controls and Noncompliance Over Reporting Responsible Official’s Response and Corrective Action Plan We concur with the findings. We acknowledge the importance of adhering to the federal guidelines for the submission of the reporting package within the mandated nine-month period. To address this, BCI will implement the following actions: 1. Policies and Procedures Development: We will create and enforce comprehensive policies and procedures to ensure that audits are initiated and completed promptly. This will include detailed timelines and checkpoints to monitor progress throughout the audit process. In addition, we will adhere to a year-end closing process that reconciles all significant accounts. 2. Training for Grant Administration: We will provide training for individuals responsible for administering federal assistance programs within BCI. This training will cover essential aspects of grant administration, ensuring that our team is well-equipped to manage these programs efficiently and in compliance with federal requirements. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, President & CEO

View Audit 403640

Finding 1217419 (2024-010)

Material Weakness 2024

Community Legal Aid Society, Inc.

DE

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.1 § 200.303 § 200.32

This has been corrected with current staff. We are making sure that all reports are filed on time and correctly. Responsible Official: Director of Finance Expected Completion Date: The report was corrected 4/14/2026 with the completion of the 2025 SLFRF Compliance Report.

View Audit 403627

Finding 1217383 (2024-002)

Material Weakness 2024

Human Services Alliance of Greater Prince William

VA

Allowable Costs / Cost Principles Material Weakness Internal Control / Segregation of Duties

Cost Allocation Recommendation: The Alliance must document its allocation methodology and retain support for allocation calculations, including any exceptions to the established policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in r...

Cost Allocation Recommendation: The Alliance must document its allocation methodology and retain support for allocation calculations, including any exceptions to the established policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Alliance documented the ARPA designated hours per employee and made adjustments where needed to allocate money away from ARPA funds when those were not reported. This process will be documented and all data and calculations supporting the allocations will be retained. Name of the contact person responsible for corrective action: Lisa Wolf Planned completion date for corrective action plan: July 1st 2026

View Audit 403581

Finding 1217305 (2024-003)

Material Weakness 2024

Anna Marie's Alliance

MN

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency § 200.318 § 200.326

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement wi...

Crime Victim Assistance – Assistance Listing No. 16.575 Recommendation: The Organization should continue to apply its current procurement policy to new and existing vendors to ensure proper documentation is retained in accordance with said procurement policy and SA UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will apply its current procurement policy to new and existing vendors in order to comply with applicable procurement requirements. Name(s) of the contact person(s) responsible for corrective action: Tracy Johnson, Director of Finance Planned completion date for corrective action plan: June 30, 2025

View Audit 403475

Finding 1217287 (2024-002)

Material Weakness 2024

Aha MacAv Housing Entity

AZ

Eligibility Material Weakness Internal Control / Segregation of Duties

Management's Response: AMHE Tenant Occupancy Specialist's will review and adhere to AMHE's Admission and Eligibility Program Management and Occupancy Master Requirements and will attend training courses that will help strengthen their eligibility policy and procedures. Estimated Completion Date: Imm...

Management's Response: AMHE Tenant Occupancy Specialist's will review and adhere to AMHE's Admission and Eligibility Program Management and Occupancy Master Requirements and will attend training courses that will help strengthen their eligibility policy and procedures. Estimated Completion Date: Immediately Interim Director will review the Admission and Eligibility Program Management and Occupancy requirements per AMHE's policy and procedures. This will be addressed with AMHE staff prior to 6/30/26. Responsible Party: Comptroller and Interim Director.

View Audit 403436

Finding 1217286 (2024-001)

Material Weakness 2024

Aha MacAv Housing Entity

AZ

Subrecipient Monitoring Material Weakness Reporting § 200.320

Management's Response: AMHE has established policies and procedures for the creation, approval, submission and retention of all required reports. On September 27, 2018 AMHE updated and adopted the Financial Management Policy and Procedures. Page 6, Section 8, Financial Reports states: "The TDHE must...

Management's Response: AMHE has established policies and procedures for the creation, approval, submission and retention of all required reports. On September 27, 2018 AMHE updated and adopted the Financial Management Policy and Procedures. Page 6, Section 8, Financial Reports states: "The TDHE must be able to produce accurate, current, and complete disclosure of the financial results of each of the financially assisted activities made in accordance with the financial reporting requirements of the grant or sub-grant. The TONE shall use the financial reports as tools to manage, control, ensure compliance, monitor, and inform the TDHE on its financial activities. Reports to Grant Agencies: The TDHE shall complete and submit all reports to Federal, State, and local grant agencies in accordance with, and in the format and timelines required by the agency. The Executive Director will oversee all administrative and financial reports, including the HUD Standard Form 425, the INP and the APR, before the due dates designated by HUD, as such forms and deadlines may change from time to time." AMHE will do better in adhering to our Financial Management Policy and Procedures moving forward and getting the reports submitted in a timely manner. Estimated Completion Date: Immediately AMHE will adhere to the practice of the Financial Reporting of the Financial Management Policy and Procedures. This will be addressed with AMHE staff prior to 6/30/26. Responsible Party: Comptroller and Interim Director.

View Audit 403436

Finding 1217228 (2024-005)

Material Weakness 2024

Family Promise of Hendricks County Inc.

IN

Internal Control / Segregation of Duties Subrecipient Monitoring HUD Housing Programs § 200.303

Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and...

Management acknowledges the importance of maintaining appropriate segregation of duties and documented independent review for match calculations and supporting documentation. Corrective actions implemented include the development and implementation of written procedures for preparing, reviewing, and approving match calculations and supporting documentation as well as requiring independent review and documented approval of match calculations by a staff member not involved in the preparation.

View Audit 403362

Finding 1217227 (2024-004)

Material Weakness 2024

Family Promise of Hendricks County Inc.

IN

Subrecipient Monitoring Eligibility HUD Housing Programs § 200.303

Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardize...

Management acknowledges the need to ensure that required documentation is complete and retained in each tenant file, including executed leases, required forms, inspection documentation, and other required program documents. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file to ensure all required documentation is complete prior to assistance approval. Staff have completed refresher training on timing requirements, documentation standards, and calculation procedures.

View Audit 403362

Finding 1217226 (2024-003)

Material Weakness 2024

Family Promise of Hendricks County Inc.

IN

Subrecipient Monitoring HUD Housing Programs Significant Deficiency § 200.303

Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checkl...

Management acknowledges the importance of completing rent reasonableness determinations timely (i.e., prior to lease execution) and ensuring the accuracy of amounts used in the calculation. Corrective actions implemented include the creation and use of a standardized eligibility determination checklist that requires documented supervisory sign-off in each tenant file which includes verification of the lease amount and calculation prior to lease execution. Staff have completed refresher training on timing requirements and calculation procedures.

View Audit 403362

Corrective Action Plans

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