Corrective Action Plans

Finding 1166598 (2023-002)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Material Weakness Reporting Program Income § 200.307

2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income ...

2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.

View Audit 377585

Finding 1166594 (2023-001)

Material Weakness 2023

Redevelopment Authority of the County of Berks

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...

2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.

View Audit 377585

Finding 1166494 (2023-007)

Material Weakness 2023

County of Plumas

CA

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

Schools and Roads - Grants to States (Compliance) We recommend that the County establish and implement formal procedures to ensure public notices related to Title III funds are issued and documented at least 45 days prior to any obligation or expenditure. This process should include clear assignment...

Schools and Roads - Grants to States (Compliance) We recommend that the County establish and implement formal procedures to ensure public notices related to Title III funds are issued and documented at least 45 days prior to any obligation or expenditure. This process should include clear assignment of responsibilities and retention of documentation as part of grant compliance records. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the Board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Public Hearings at least 45 days proper to obligation or expenditures. This process should include clear assignment of responsibilities and retention of documentation as part of grant compliance records; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166491 (2023-006)

Material Weakness 2023

County of Plumas

CA

Subrecipient Monitoring Eligibility Reporting § 200.328

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Manageme...

Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Certification Title III Expenditures and Unobligated Funds by statutory deadline. This process should include clear assignment to responsibilities and retention of documentation as part of grant compliance records.; Anticipated Completion Date: June 30, 2026.

View Audit 377492

Finding 1166456 (2023-001)

Material Weakness 2023

Eastern Kentucky PRIDE, Inc.

KY

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.

View Audit 377479

Finding 1166325 (2023-009)

Material Weakness 2023

Dorchester County, Maryland

MD

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

The County will implement procedures to ensure the review and approval of the monthly report is documented.

View Audit 377392

Finding 1166097 (2023-006)

Material Weakness 2023

City of Lynn

MA

Allowable Costs / Cost Principles Reporting Significant Deficiency

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...

Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025

View Audit 376863

Finding 1165780 (2023-002)

Material Weakness 2023

City of Springfield

OH

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training...

Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training to staff on SLFRF reporting requirements and deadlines, implement written policies and procedures to ensure timely submission of all reports, including establishing a compliance calendar with automated reminders and maintaining a reporting log to track submission dates. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Katie Eviston, Finance Director, (937) 324-7700

View Audit 376568

Finding 1165777 (2023-003)

Material Weakness 2023

City of Springfield

OH

Subrecipient Monitoring HUD Housing Programs Internal Control / Segregation of Duties

Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties ar...

Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties are accurately monitored, and will confirm that responsibility for scheduling and completing inspections is clearly assigned to a designated staff member within the Community Development department. Overdue inspections will be completed promptly, with results documented in accordance with HUD requirements. In addition, the City will review and revise current policies and procedures to strengthen inspection scheduling, address staff turnover contingencies, and improve compliance monitoring. Staff will receive updated training on HUD property standards and inspection requirements to ensure ongoing compliance. Progress will be monitored quarterly, and updates will be provided to management and the governing body. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Logan Cobbs, Community Development Director, (937) 324-7381

View Audit 376568

Finding 1165703 (2023-005)

Material Weakness 2023

Eldred Borough

NY

Internal Control / Segregation of Duties Reporting § 200.303

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...

Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.

View Audit 376427

Finding 1165699 (2023-004)

Material Weakness 2023

Eldred Borough

NY

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties § 200.512

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.

View Audit 376427

Finding 1165695 (2023-003)

Material Weakness 2023

Eldred Borough

NY

Procurement, Suspension & Debarment Reporting Internal Control / Segregation of Duties § 200.512

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...

Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.

View Audit 376427

Finding 1164722 (2023-003)

Material Weakness 2023

Chrysalis Center

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.403 § 200.430

Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal proce...

Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal process for preparation of the SEFA. Recommendation: Management should prepare a master tracking schedule for government grants which includes the source of funding and audit and reporting requirements. The schedule should be prepared by someone with knowledge of the grant agreements and reviewed by a leader in the accounting department to ensure completeness. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management has implemented a master tracking schedule for government grants that includes the source of funding and audit and reporting requirements. This tracker is a joint effort between finance and grants management teams. Anticipated Completion Date: December 31, 2025

View Audit 374440

Finding 1164634 (2023-004)

Material Weakness 2023

Northeast Treatment Centers, Inc.

PA

Internal Control / Segregation of Duties

Recommendation: We recommend that management ensures that there is documented approval for all employees’current pay rates and that a copy of all employee’s work documents (I-9, W4, background checks) are kept on file in line with the Centers’ policies Explanation of Disagreement with Audit Finding:...

Recommendation: We recommend that management ensures that there is documented approval for all employees’current pay rates and that a copy of all employee’s work documents (I-9, W4, background checks) are kept on file in line with the Centers’ policies Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented a new payroll system and new policies within the HR department to ensure documentation is maintained electronically to support pay rates as well as maintaining all employee documents, including I-9, W4 and background checks. Name of the contact person responsible for corrective action: Regan Kelly, CEO of NorthEast Treatment Centers, Inc. (215) 451-7000

View Audit 374237

Finding 1164633 (2023-003)

Material Weakness 2023

Net Treatment Services, Inc. D/b/a Net Community Care

PA

Questioned Costs Student Financial Aid Cash Management

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: J...

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: July 1, 2022 through June 30, 2023 Type of Finding: Material Weakness in Internal Control over Compliance and Cash Management Recommendation: We recommend that management ensure that all invoices are based on actual expenses incurred and that there is a review an approval process of invoices before submission. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Aciton take in response to finding: Management has implemented a policy which requires each invoice to be based only on actual expenses incurred for the period and prohibits the use of a straight-line calculation to draw down funds. Invoices are also approved by the CFO prior to submission for reimbursement. Name of contact person responsible for corrective action: Regan Kelly, CEO of NorthEast Treatment Cetners, Inc. (215) 451-7000 Planned completion date for corrective action plan: January 31, 2024

View Audit 374235 Questioned Costs: $1

Finding 1164330 (2023-001)

Material Weakness 2023

JXN Water

MS

Internal Control / Segregation of Duties

JXN Water, Inc. hired Horne LLP to assist with grant management in May 2024. Additionally, EPA instituted new procedures in March 2024, requiring all grant funded invoices be submitted and approved by EPA prior to releasing funds from the two grants. Going forward JXN Water, Inc. is looking to hire ...

JXN Water, Inc. hired Horne LLP to assist with grant management in May 2024. Additionally, EPA instituted new procedures in March 2024, requiring all grant funded invoices be submitted and approved by EPA prior to releasing funds from the two grants. Going forward JXN Water, Inc. is looking to hire a construction contract manager to review and approve all construction related invoices prior to payment. Non construction invoices will be approved by the JXN Water, Inc. Administrative Manager prior to payment in BILL.COM. These changes should be in place by December 31, 2024.

View Audit 373772

Finding 1164324 (2023-005)

Material Weakness 2023

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties

Subsequent to year-end, the District’s Board approved a written policy on internal controls over grant funds.

View Audit 373746

Finding 1164322 (2023-003)

Material Weakness 2023

Consolidated Public Water Supply District No 1 of Clark County Mo

MO

Internal Control / Segregation of Duties HUD Housing Programs

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursement...

The Board and management are aware of the inadequate separation of accounting duties when reviewing the monthly operations and financial results of the District. As an ongoing mitigating control, at the board meetings management and the board members review the monthly check register of disbursements, interim financial reports, summary of cash and certificates of deposits held, and contract pay applications and construction project status as presented by the project engineer for review and approval by the Board.

View Audit 373746

Finding 1164298 (2023-002)

Material Weakness 2023

Commonwealth Utilities Corporation

MP

Reporting Internal Control / Segregation of Duties § 200.328

Person Responsible: Fiscal Administrator (Grants and Budget) Deadline: CUC agrees to develop and create a more refined tracking system and staffing for compliance purposes. A tracking system is in place as of this writing.

View Audit 373671

Finding 1164261 (2023-010)

Material Weakness 2023

Bristlecone Family Resources

CA

Eligibility Material Weakness Reporting

Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025

View Audit 373603

Finding 1163470 (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 373080

Finding 1163399 (2023-004)

Material Weakness 2023

CUMAC/ECHO, Inc.

NJ

Internal Control / Segregation of Duties Reporting

Finding --- The Organization did not submit its Single Audit reporting package, Including the data collection form (Form SF-SAC), to the Federal Audit Clearinghouse within the required timeframe following the end of the fiscal year. The report was not filed and therefore not made available to users ...

Finding --- The Organization did not submit its Single Audit reporting package, Including the data collection form (Form SF-SAC), to the Federal Audit Clearinghouse within the required timeframe following the end of the fiscal year. The report was not filed and therefore not made available to users timely. Corrective action – The Organization will seek to achieve a timelier closing process and audit submission. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07505

View Audit 372936

Finding 1163397 (2023-002)

Material Weakness 2023

CUMAC/ECHO, Inc.

NJ

Internal Control / Segregation of Duties

Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action – Management understands the risk involved and will update policies and procedures to clearly define and create segregation of duties. Status --- Corrective action in progress. Completion d...

Finding --- Internal controls over financial statement reporting lack segregation of duties. Corrective action – Management understands the risk involved and will update policies and procedures to clearly define and create segregation of duties. Status --- Corrective action in progress. Completion date --- Before December 31, 2025 Contact --- Laura Purdy, COO Contact phone --- (973) 742-5518 Contact address --- 223 Ellison St., Paterson, New Jersey 07

View Audit 372936

Finding 1163319 (2023-004)

Material Weakness 2023

Abilities Network, Inc.

MD

Allowable Costs / Cost Principles Period of Performance Significant Deficiency § 200.303

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...

U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.

View Audit 372833

Finding 1163294 (2023-005)

Material Weakness 2023

First Nations Community Healthsource, Inc.

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal...

Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal controls to guarantee the timely preparation and accurate submission of reports and records for audit purposes, particularly in alignment with the requirements outlined in 2 CFR 200.512. To effectively implement these internal controls, management will enforce procedures for the timely preparation of all necessary reports and records, including the Schedule of Expenditures of Federal Awards (SEFA). This will not only facilitate smoother audit processes but also ensure adherence to the 2 CFR 200.512. Management will train staff and establish timelines and responsibilities for report preparation and documentation to enhance compliance and streamline overall operations. Expected Outcome: -On-time Single Audit filings in compliance with federal rules. -Clear visibility and accountability for deadlines. -Reduced risk of penalties and funding delays. -Greater confidence from agencies and stakeholders. Due Date of Completion: 3 days following issuance of the audit report Responsible Party(ies): CEO, CFO

View Audit 372817

Corrective Action Plans

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