Corrective Action Plans

Finding 1155062 (2024-005)

Material Weakness 2024

Muskogee County

OK

Internal Control / Segregation of Duties

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, an...

The Board of County Commissioners will work with all elected officials, the new county grant administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements.

View Audit 367369

Finding 1155031 (2024-001)

Material Weakness 2024

Watts Healthcare Corporation

CA

Questioned Costs Subrecipient Monitoring Cash Management

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients a...

Management will implement the following corrective actions to address the root causes and prevent recurrence: • Policy Clarification – Categories A–D of the sliding fee schedule apply only to patients at or below 200% FPG. Category E is designated as a deposit/minimum payment category for patients above 200% FPG, with no discount applied. • Patient Reclassification – All previously misclassified patients are being reclassified to full-pay status. Prior balances will be reconciled in accordance with HRSA requirements and organizational policy. • Staff Training – Front office, billing, and eligibility staff will undergo mandatory refresher training on the Sliding Fee Discount Program, income verification, and proper application of the fee schedule. Additional refresher training on Self-Pay procedures will be led by the Director of Member Services. • Ongoing Monitoring – A quarterly compliance audit of the sliding fee program has been implemented. Results will be reviewed by management, with corrective actions taken as necessary. • Transparency & Communication – Patients will be notified in writing of their payment category. Appeals or questions will be addressed per organizational policy and HRSA guidelines. • Financial Remediation – Refunds will be issued to patients who were overcharged. For cases involving undercharges, the outstanding balance will be applied to the patient’s next visit. Personnel responsible for implementation: Jose Juarez, Director of Member Services Date of implementation: August 31, 2025

View Audit 367364 Questioned Costs: $1

Finding 1155029 (2024-001)

Material Weakness 2024

Bauer Family Resources, Inc.

IN

HUD Housing Programs Material Weakness Reporting

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house a...

Recommendation: The Organization should follow established controls to ensure timely submission of the Data Collection Form. This should include assignment of responsibility to a designated official and be monitored by management. Corrective Actions: Our accounting department is now fully in-house and all partnerships with the outside accounting firm, Wipfli, have been terminated. This year and moving into the future, we do not anticipate having any issues with completing our audit on time. This audit for 2024 will be completed in a timely manner.

View Audit 367354

Finding 1154988 (2024-001)

Material Weakness 2024

City of Redfield

SD

Internal Control / Segregation of Duties Material Weakness Reporting

When federal compliance issues arise, the City Finance Officer will communicate them to the Mayor

View Audit 367338

Finding 1154981 (2024-009)

Material Weakness 2024

Silver Key Senior Services, Inc.

CO

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.516

Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controlle...

Corrective Plan of Action: Silver Key Senior Services has had review and approval processes in place since early 2024; however, gaps arose in consistent documentation. Going forward, all compliance procedures will be followed and documented, including documenting verbal communications. All Controller (new role in lieu of CFO) approvals will be maintained in writing, and transactions by the Controller will continue to be reviewed by the CEO. Quarterly spot checks will be conducted to confirm compliance. Anticipated Completion Date: Corrections were made as soon as the issue was identified; procedures are now in place to ensure consistent documentation

View Audit 367331

Finding 1154978 (2024-003)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to implement the water shut-off policy consistently.

View Audit 367318

Finding 1154977 (2024-002)

Material Weakness 2024

Elm Hill Water District

MA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports a...

Views of Responsible Officials and Corrective Action: The District will strive to gain necessary knowledge needed to prepare a full set of financial statements. The District will appoint a competent individual who possesses the skill knowledge and experience to review and approve the draft reports and assume all relevant management responsibilities.

View Audit 367318

Finding 1154976 (2024-001)

Material Weakness 2024

Elm Hill Water District

MA

Significant Deficiency Internal Control / Segregation of Duties

Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.

View Audit 367318

Finding 1154958 (2024-002)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.430 § 200.512

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and...

Finding: 2024-002 Improper Approvals of Payroll Name of contact person: Vince Collins, Executive Director Corrective Action: the Organization started its formal approval process for pay raises and pay changes during 2025. As a part of the Organization’s remediation they created formal agreements and pay raise letters for approvals. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154957 (2024-001)

Material Weakness 2024

Recovery Cafe of Clark County

WA

Reporting Internal Control / Segregation of Duties § 200.512

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of ...

Finding: 2024-001 Single Audit Completion and Submission Name of contact person: Vince Collins, Executive Director Corrective Action: The Organization started its remediation of its accounting closing processes during 2025. Timely and accurate accounting records will ensure the timely completion of future reporting requirements for the Organization. Proposed Completion Date: Before September 30, 2025, the Organization’s 2024 audit period single audit submission deadline.

View Audit 367294

Finding 1154955 (2024-003)

Material Weakness 2024

Waushara County

WI

Reporting Significant Deficiency Internal Control / Segregation of Duties

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and...

Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: CLA recommends the County develop and implement a process to require review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate, complete and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Annual WIMCR reporting to be completed by Waushara County DHS Finance team; Financial Manager and/or Financial Assistant. If both positions are fully employed both positions need to review and sign off on data prior to submission. If one of the positions is vacant a second review of data and signoff needs to be done by someone else within DHS – likely the DHS Director. Name(s) of the contact person(s) responsible for corrective action: Peder Culver, Finance Manager, Clara Voigtlander, DHS Director Planned completion date for corrective action plan: Action plan in place 2025 reporting in 2026.

View Audit 367288

Finding 1154942 (2024-004)

Material Weakness 2024

Bronx Community Health Network, Inc.

NY

Allowable Costs / Cost Principles HUD Housing Programs Period of Performance § 200.303

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencin...

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-004 – Period of Performance Description of Finding: There was no evidence, such as a signature, evidencing review and approval by a direct supervisor of the timesheets. Time and effort reports were not done. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN has put together a training program for employees to ensure that timecards are reviewed and approved by both the employee and the supervisor on a bi-weekly basis. Before payroll is processed, approvals by employees and supervisors will be checked. HR will provide a monthly time and effort report to the finance team. This report will provide total number of hours worked by each employee for each assigned cost center. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

View Audit 367254

Finding 1154922 (2024-004)

Material Weakness 2024

City of Owatonna

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Th...

Lack of Procurement Policy – Procurement, Suspension and Debarment Federal Agency: U.S. Department of Treasury Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: We recommend the City adopt a procurement policy that includes procedures over suspension and debarment. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The City will prepare a policy and have it adopted by the City Council. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.

View Audit 367241

Finding 1154921 (2024-003)

Material Weakness 2024

Housing and Redevelopment Authority of Owatonna

MN

Internal Control / Segregation of Duties Eligibility Material Weakness

Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Ag...

Lack of Proper Review – Eligibility, Reporting, and Special Provisions Federal agency: U.S. Department of Housing and Urban Development Federal program Title: Housing Choice Voucher Program Assistance Listing Number: 14.871 and 14.879 Federal Award Identification Number and Year: N/A Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: December 31, 2024 Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: We recommend the HRA implement controls over all areas of the federal program so that controls are in place and working. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: The HRA will assess the controls over the federal program and make changes as deemed necessary. Name of the Contact Person Responsible for Corrective Action Plan: Emily Burns, Finance Manager Planned Completion Date for Corrective Action Plan: December 31, 2025.

View Audit 367240

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

Corrective Actions Taken:

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

1. Policy Adoption: A formal disbursement approval policy was adopted in 2024. The policy defines required documentation, establishes tiered approval thresholds, and assigns authorization responsibility based on role.

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

2. System Controls: SCMRC’s accounting system was configured to require digital documentation of disbursement approvals. All disbursements are now traceable to authorized personnel.

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

3. Routine Oversight: The CEO and contract accountant conduct quarterly sampling of disbursement activity to verify proper documentation and authorization.

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

4. Board Involvement: SCMRC’s Finance Committee reviews disbursement policies and internal controls annually as part of the broader fiscal oversight process.

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK

Internal Control / Segregation of Duties

5. Staff Training: Finance and administrative staff received updated training in 2024 on disbursement procedures and documentation protocols.

View Audit 367237

Finding 1154902 (2024-009)

Material Weakness 2024

South Central Medical and Resource Center, Inc.

OK