Corrective Action Plans

Finding 1225743 (2025-002)

Material Weakness 2025

MI

Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in the Ingham County, Michigan Single Audit report for the year ended December 31, 2025, and corrective actions to be completed. 2025-002 – Procurement, Suspension and Debarm...

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in the Ingham County, Michigan Single Audit report for the year ended December 31, 2025, and corrective actions to be completed. 2025-002 – Procurement, Suspension and Debarment Auditor Description of Condition and Effect. While the County indicated that they have been completing suspension and debarment checks on County vendors in the past, evidence of these suspension and debarment checks was not retained and made available for audit. As a result of this condition, the County was exposed to the risk that disbursements of federal awards would be made to vendors suspended or debarred by the federal government and subject to disallowance by the grantor. Auditor Recommendation. We recommend that the County verify that any of their vendors with $25,000 spent with federal funds were not suspended or debarred and that documentation of these procedures be retained. Corrective Action. The County will review vendors over $25,000 spent with federal funds to ensure that they are not suspended or debarred and retain documented support for the procedures performed. Responsible Person. Andrea Shetenhelm, Interim Finance Director Anticipated Completion Date. December 31, 2026

View Audit 408546

Finding 1225718 (2025-005)

Material Weakness 2025

Housing Authority of the City of Seattle

WA

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure enforcement of HQS. These controls should include assigning a responsible individual to manage the reinspection schedule and to monitor and fol...

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure enforcement of HQS. These controls should include assigning a responsible individual to manage the reinspection schedule and to monitor and follow up on all reinspection dates, preventing inconsistent and missed reinspection. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The shift from HQS to NSPIRE protocol created a confusing inspection record with duplicate inspection entries. SHA has completed a review of all same day inspection entries and found no other examples of the first identified exception. In 2025 and 2026 SHA has strengthened oversight of inspections non-compliance processes. New workflows display units by category of action needed. Staff are able to see clearly what action is required and supervisors and the compliance team review the workflows regularly for accountability. The inspections non-compliance workgroup from the previous year’s action plan has concluded its work and resolved outstanding inspections non-compliance. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Was in progress during this audit period and is now complete.

View Audit 408541

Finding 1225707 (2025-004)

Material Weakness 2025

Housing Authority of the City of Seattle

WA

HUD Housing Programs Internal Control / Segregation of Duties

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy....

Housing Choice Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has adopted the HUD form 9886-A which does not expire. Due to SHA’s triennial review process, not all participants have been required to sign the new 9886-A and update SHA General Release of Information. All participants will be updated to the new forms at the end of the triennial cycle. Additionally, all elements of the 2025-002 action plan apply to this finding. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Continuous.

View Audit 408541

Finding 1225696 (2025-003)

Material Weakness 2025

Housing Authority of the City of Seattle

WA

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure housing inspections are performed when due. Such controls should include assigning a responsible individual to manage the inspection schedule and to...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure housing inspections are performed when due. Such controls should include assigning a responsible individual to manage the inspection schedule and to monitor and follow up on all inspection dates to prevent missed inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA was in the process of completing its corrective action plan in 2025 and addressing past due inspections. This unit was appropriately identified as needing inspection and added to the action plan. Prior to an inspection the participant left the program and no inspection was necessary as the unit was no longer under a HAP contract. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa Planned completion date for corrective action plan: Was in progress during this audit period and is now complete.

View Audit 408541

Finding 1225690 (2025-002)

Material Weakness 2025

Housing Authority of the City of Seattle

WA

HUD Housing Programs Internal Control / Segregation of Duties

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Expl...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SHA has added multiple additional elements to a total quality management approach to certification processing. An additional occupancy manager was hired in 2025 to increase oversight capacity for eligibility and certification processes. Also 5 additional certification specialists are in training to add overall work capacity, with training planned to be completed in August of 2026. The additional certification specialists will mitigate the impacts of staff turnover and large caseloads. A rollout of KPI reporting and accountability measures is currently underway and will be completed by September 2026. The reporting includes individual level review of current work in multiple areas as well as manager review templates for increased visibility and accountability. Monthly trainings in 2026 will highlight documentation and timeline requirements. The one tenant file noted for lack of supporting documentation that the reexamination was complete is a project-based voucher unit operated by the Housing Operations Department under Move to Work activity 15.A.01. This activity enables the Authority to manage project-based voucher units under the public housing program regulations. The corrective action plan for this issue reflects this activity. Housing Operations has recently implemented a new Electronic Filing System Guide and updated procedures outlining electronic filing and record retention requirements. The updated procedure establishes a requirement for supervisors to regularly audit the quality, accuracy, and timeliness of file documentation. Name(s) of the contact person(s) responsible for corrective action: Alice Kimbowa and Dave Wellings Planned completion date for corrective action plan: Continuous. Compliance will provide staff with refresher training on the new filing system guide and procedures, as well as Rent Calculation Training that includes guidance on income determination and income verification standards. Compliance will continue to conduct regular audits of public housing eligibility and recertification files to ensure ongoing adherence to HUD requirements and SHA policy.

View Audit 408541

Finding 1225684 (2025-001)

Material Weakness 2025

Housing Authority of the City of Seattle

WA

HUD Housing Programs Internal Control / Segregation of Duties

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing income eligibility, in accordance with federal regulation and Authority polic...

Moving to Work Demonstration Program – Assistance Listing No. 14.881 Recommendation: We recommend the Authority design and implement controls to ensure tenant files include documentation supporting both initial and ongoing income eligibility, in accordance with federal regulation and Authority policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Housing Operations has recently implemented a new Electronic Filing System Guide and updated procedures outlining electronic filing and record retention requirements. The updated procedure establishes a requirement for supervisors to regularly audit the quality, accuracy, and timeliness of file documentation. Compliance will provide staff with refresher training on the new filing system guide and procedures, as well as Rent Calculation Training that includes guidance on income determination and income verification standards. Compliance will continue to conduct regular audits of public housing eligibility and recertification files to ensure ongoing adherence to HUD requirements and SHA policy. Name(s) of the contact person(s) responsible for corrective action: Dave Wellings Planned completion date for corrective action plan: Year end 2026 and then on-going training and internal audit procedures.

View Audit 408541

Finding 1225618 (2025-005)

Material Weakness 2025

White Bird Clinic

OR

Questioned Costs Special Tests & Provisions Material Weakness

2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for F...

2025-005 Special Tests Corrective action planned: WBC Management agrees with this finding. WBC has created and hired for a new position, Revenue Cycle Manager (RCM). The RCM has oversight of Revenue generated through the FQHC Clinics. As part of this oversight, the RCM is implementing training for Front Office staff that are responsible for gathering and inputting client data related to calculation of the Slide. In addition to internal training of Front Office staff, WBC will be engaging an external expert to review and revise applicable policies and procedures to ensure alignment with best practices. The RCM is also responsible for conducting periodic internal reviews of documentation supporting Slide calculations to ensure support matches with the calculated Slide rate. Anticipated completion date: 2026, July Contact person responsible for corrective action: Amee Markwardt, Executive Director

View Audit 408513

Finding 1225617 (2025-004)

Material Weakness 2025

White Bird Clinic

OR

Questioned Costs Allowable Costs / Cost Principles Material Weakness

2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were ca...

2025-004 Reporting Corrective action planned: WBC Management agrees with this finding. WBC had to switch EHRs during 2023 and 2024, which required our Dental, Medical, and Behavioral Health programs to use their own separate EHR to alleviate critical functional and capacity deficiencies that were caused by our previous EHR. This resulted in significantly more complexity when calculating our UDS numbers. The process involved combining all of our patient demographics and accounting for overlapping (duplicate encounters) by hand. This was made all the more difficult by name misspellings and other errors during data entry. Relating to our prior year finding, WBC had contracted with a third party to implement a custom population health tool to automate our UDS reporting. The contractor did not meet specified deliverable requirements, so reporting was again done manually, which resulted in the errors. White Bird Clinic has been working to evaluate population health tools to aggregate patient data to provide more accurate UDS and clinical quality reporting. In 2026, through the help of our HCCN, Health Efficient, we contracted with Relevant Health to implement their population health tool to streamline and accurately report our population health and our UDS reporting. The Relevant platform is in use by over 100 FQHCs across the country. This tool will aggregate patient data from each EHR, account for duplicates, and accurately report combined UDS demographics from all our systems. They are very experienced with UDS and UDS+ reporting, so the system is designed to seamlessly provide accurate and consistent UDS metrics and address duplicate clients from multiple EHRs. Anticipated completion date: 2026, July Contact person responsible for corrective action: Tyler Stewart, Director of IT

View Audit 408513

Finding 1225603 (2025-001)

Material Weakness 2025

INTERCAMBIOS PUERTO RICO, INC

PR

Questioned Costs Subrecipient Monitoring Reporting § 200.512

Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve a...

Views of Reasonable Officials and Corrective Actions Organization will engage in assessing specific staffing needs (FY26), seeking additional funds (FY26 & FY27),and increasing the capacity of the team in charge of providing services in accounting and organizational funds(FY27) in order to achieve accurate and timely reporting. Name(s) of the Contact Person(s) Responsible for Corrective Action Rafael A Torruella, Ph.D.- Executive Director Anticipated Completion Date During FY 2025-2026 & FY2026-2027

View Audit 408485

Finding 1225595 (2025-001)

Material Weakness 2025

Healthcare for the Homeless - Houston

TX

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patie...

Management is Responsible for Obtaining and Retaining Patient Intake Forms to Remain Compliant with Sliding Fee Discount Requirements Management’s view: Management agrees with the condition described. Proposed corrective action: Management will strengthen procedures for obtaining and retaining patient intake documentation to ensure ongoing compliance with sliding fee discount requirements. Front-desk and registration staff will be retrained on intake form completion and annual renewal requirements, with clear accountability assigned for verifying documentation at each patient visit. A weekly compliance monitoring report will be implemented to identify missing or outdated intake forms before they age past the current review period, allowing for timely follow-up. Registration workflows will be refined to build in a review checkpoint at the point of service, and the Organization will add dedicated intake staffing capacity to provide consistent oversight of this function going forward. These steps will strengthen controls and ensure patient intake documentation is properly obtained, updated, and retained in compliance with sliding fee discount requirements. Anticipated correction date: Some corrective action was implemented in Q1 and Q2 2026. This is expected to be fully implemented effective by Q4 2026. Responsible official: Kathryn Rogers, Executive Vice President

View Audit 408476

Finding 1225594 (2025-003)

Material Weakness 2025

Metcalfe County Fiscal Court

KY

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested ...

The Metcalfe County Fiscal Court will establish internal controls over the federal expenditure process when a third-party entity is involved to ensure all compliance and recording requirements are met. Although the Metcalfe County Fiscal Court was in compliance with federal requirements when tested by a single audit, having these procedures in place will ensure that all future federal expenditures will remain in compliance.

View Audit 408468

Finding 1225590 (2025-002)

Material Weakness 2025

Princeton Housing Authority

NJ

Questioned Costs Internal Control / Segregation of Duties

Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible ...

Authority's Response and Planned Corrective Action Plan: The Authority agrees with the finding and will strengthen payroll review procedures to ensure compensation is properly authorized, documented, and reconciled to Board-approved salary schedules. Tyler Martin, Executive Director, is responsible for ensuring the deficiencies have been rectified by June 30, 2026.

View Audit 408466

Finding 1225589 (2025-015)

Material Weakness 2025

Woodland Park School District Number Re-2

CO

School Nutrition Programs Internal Control / Segregation of Duties

Eligibility for the Child Nutrition Cluster (Federal Award) Implement system edits or procedural checks to prevent duplicate eligibility entries for the same student, including unique student identifiers and warning prompts. Periodically run and review reports identifying potential duplicate records...

Eligibility for the Child Nutrition Cluster (Federal Award) Implement system edits or procedural checks to prevent duplicate eligibility entries for the same student, including unique student identifiers and warning prompts. Periodically run and review reports identifying potential duplicate records (same student ID, name, date of birth) and investigate and clear duplicates. Provide training to Nutrition Services staff on maintaining an unduplicated eligibility file and correcting errors. Responsible Party - Child Nutrition Analyst Target Completion - December 31, 2026

View Audit 408462

Finding 1225580 (2025-001)

Material Weakness 2025

Martha's Vineyard Regional High School District

MA

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

Time & Effort Documentation. Due to the timing of the retirement of the SPED Administrative Assistant who was responsible for documenting the time & effort of staff paid for from the SPED 240 Grant, the necessary paperwork/documentation was not collected as required. The Corrective Action Plan will ...

Time & Effort Documentation. Due to the timing of the retirement of the SPED Administrative Assistant who was responsible for documenting the time & effort of staff paid for from the SPED 240 Grant, the necessary paperwork/documentation was not collected as required. The Corrective Action Plan will consist of training the new SPED Administrative Assistant on this requirement, and to have multiple check-ins during the year with the Director of Support Services and the SPED Administrative Assistant on this requirement. Lastly, we are taking the additional step to add language into each annual payroll contract of staff funded from the SPED 240 Grant, that they are funded, and to what proportion, by that grant. This will be overseen by the School Business Administrator in concert with the Director of Support Services, and will be effective for the FY26 Single Audit cycle.

View Audit 408454

Finding 1225548 (2025-001)

Material Weakness 2025

Bang on A Can

NY

Reporting Internal Control / Segregation of Duties

Bang on a Can, Inc. will implement procedures to provide for accounting and financial reporting on the accrual basis of accounting.

View Audit 408442

Finding 1225522 (2025-002)

Material Weakness 2025

Franklin County

IN

Internal Control / Segregation of Duties § 200.1 § 200.303

FINDING 2025-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Karla Bauman Contact Phone Number and Email Address: (765) 647-4631, auditor@franklincounty.in.gov Views of Responsible Officials: INDIANA STATE ...

FINDING 2025-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Karla Bauman Contact Phone Number and Email Address: (765) 647-4631, auditor@franklincounty.in.gov Views of Responsible Officials: INDIANA STATE BOARD OF ACCOUNTS 20 We concur with the finding. The expenditures overstated by $88,800 was a result of an adjustment that was done in April, 2025. The overstated current period obligations and cumulative obligations were reported as the annual or cumulative expenditure amount (project total) instead of obligations remaining under contract. Description of Corrective Action Plan: Upon reviewing the errors as described in Finding 2025-002, with the annual report that was filed for the reporting period April 1, 2025 thru March 31, 2026, expenditures were correctly stated. Corrections for any “obligations” will be made on the final close out report. Notes will be added to explain what was misreported under any project for current period obligations and/or cumulative obligations and what the correct amount should have been. Anticipated Completion Date: The expenditures were corrected with the report filed in April, 2026 for reporting period April 1, 2025 thru March 31, 2026. A note will be added to the close out report for the adjustment that was made in April, 2025 for a transaction done in March of 2025 in the sum of $88,800. All corrections for current period or cumulative obligations will be completed on the close out report with notes describing the error in previously reported. INDIANA STATE

View Audit 408412

Finding 1225519 (2025-007)

Material Weakness 2025

County of Orangeburg

SC

Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: We concur with the finding. The County is in the process of implementing controls and procedures to ensure reporting are being performed in order to be compliant with requirements under the Uniform Guidance and the ReConnect Program.

View Audit 408402

Finding 1225518 (2025-006)

Material Weakness 2025

County of Orangeburg

SC

Reporting Internal Control / Segregation of Duties

Views of Responsible Officials and Planned Corrective Action: We concur with the finding. The County is in the process of implementing controls and procedures to ensure reporting are being performed in order to be compliant with requirements under the Uniform Guidance and the SLFRF Program.

View Audit 408402

Finding 1225517 (2025-001)

Material Weakness 2025

Garnet Valley School District

PA

Allowable Costs / Cost Principles Significant Deficiency Matching / Level of Effort / Earmarking

The District will implement formal review procedures to verify compliance with maintenance of effort requirements during the budgeting process, including verification of required per-pupil thresholds prior to approval. Documentation of these compliance checks will be prepared, reviewed, and retained...

The District will implement formal review procedures to verify compliance with maintenance of effort requirements during the budgeting process, including verification of required per-pupil thresholds prior to approval. Documentation of these compliance checks will be prepared, reviewed, and retained as part of the budget workpapers. In addition, business office and program staff involved in the development of IDEA budgets will receive training on federal eligibility requirements to reduce the risk of recurrence.

View Audit 408397

Finding 1225513 (2025-004)

Material Weakness 2025

Montgomery County, Il

IL

Procurement, Suspension & Debarment Subrecipient Monitoring Period of Performance

Condition: The County approved to purchase generators for the Village of Taylor Springs on June 11, 2024 with Ordinance 2024-12. However, due to unavailability, these generators were not purchased until June 2025. Approving an ordinance does not fall under the definition of obligating funds under AR...

Condition: The County approved to purchase generators for the Village of Taylor Springs on June 11, 2024 with Ordinance 2024-12. However, due to unavailability, these generators were not purchased until June 2025. Approving an ordinance does not fall under the definition of obligating funds under ARPA. Plan: We recommend that applicable County employees and board members research all procurement compliance requirements when grants are received. Name of Contact Person: Nikki Lohman, Treasurer Management Response: Due to the generator not being available at the time of ordinance, it was an oversight that the actual obligation was incurred after the period of performance. The County did try in good faith to order the generator before the deadline. Anticipated Date of Completion: March 2026, anticipated date of ARPA funds being fully expensed.

View Audit 408395

Finding 1225510 (2025-001)

Material Weakness 2025

Su Casa Community Housing Association

CA

Subrecipient Monitoring HUD Housing Programs Reporting

Finding 2025-001 – Improper approval of invoices Recommendation: We recommend that management should enhance invoice review and approval procedures to ensure that expenses are recorded in the period in which the related services are performed, in accordance with U.S. GAAP and HUD requirements. Appro...

Finding 2025-001 – Improper approval of invoices Recommendation: We recommend that management should enhance invoice review and approval procedures to ensure that expenses are recorded in the period in which the related services are performed, in accordance with U.S. GAAP and HUD requirements. Approval of invoices should require verification of service dates and services performed prior to recording the expense in the general ledger. Cutoff procedures should be formalized at year-end to identify and accrue expenses for services received but not yet invoiced or approved. Supervisory reviews of expense coding and timing should be performed to confirm compliance with both financial reporting and HUD. View of Responsible Officials and Planned Corrective Action: The previous management company has been replaced with a new management company. The new management company provides complete transparency and reports directly to the Board. Existing invoice review, approval and monitoring procedures are now being consistently followed and enforced to ensure that expenses are properly reviewed and recorded in the appropriate accounting period. In addition, purchasing and payment transactions are subject to multiple levels of approval and oversight to help ensure compliance with established policies, proper authorization of expenditures and accurate financial reporting. Management response: Management agrees with the recommendation. Action Taken: The previous management company has been replaced with a new management company. The new management company provides complete transparency and reports directly to the Board. Existing invoice review, approval, and monitoring procedures are now being consistently followed and enforced to ensure that expenses are properly reviewed, approved, and recorded in the appropriate accounting period. In addition, purchasing and payment transactions are subject to multiple levels of approval and oversight to help ensure compliance with established policies, proper authorization of expenditures, and accurate financial reporting.

View Audit 408391

Finding 1225495 (2025-002)

Material Weakness 2025

La Pine Community Health Center

OR

Subrecipient Monitoring Significant Deficiency Internal Control / Segregation of Duties § 200.303

Action taken in response to finding: The organization has implemented a procedure to review and approve required reports prior to submission.

View Audit 408356

Finding 1225492 (2025-001)

Material Weakness 2025

La Pine Community Health Center

OR

Eligibility Significant Deficiency Internal Control / Segregation of Duties

Action taken in response to finding: The organization has worked with appropriate staff to provide further clarification on sliding fee intake and approval process.

View Audit 408356

Finding 1225399 (2025-002)

Material Weakness 2025

H.O.P.E. HELPING OURSELVES PREVENT EMERGENCIES

AK

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies...

Criteria: The objective of the Assistance Listing 93.912 is to improve services for substance use disorder (SUD) and opioid use disorder (OUD) through prevention, treatment, and recovery services. Management is responsible for establishing and maintaining internal controls, including formal policies and procedures for the review and approval of journal entries, adjustments to expenditures, and account reconciliations, to ensure expenditures reported to granting agencies are complete, accurate, allowable, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment -Once we were made aware of this finding through the audit, we began thinking of the most efficient way to document the Board’s knowledge and approvals of journal entries, including adjustments to expenditures and account reconciliations. Root Cause -HOPE is currently revising all policies and procedures. This was HOPE’s first federal single audit, so once we heard of the finding we prioritized revisions of fiscal policies and procedures to address the finding. Action Taken- The first board meeting after learning of this finding will be held on July 27th, 2026. Beginning with that meeting, the Board’s approval of the statement of activity detail, consisting of all charges and journal entries entered into HOPE’s accounting system since the date of the last Board meeting, will be approved via motion and seconded and noted as such in the Board meeting minutes. Most journal entries made during the month are currently entered into the system by HOPE’s CPA. The remaining journal entries are entered by HOPE’s Executive Director. To ensure that the Board is aware of the adjustments made in the system, all journal entries made since the last Board meeting will be approved via a motion and a second as a separate agenda item to ensure that the Board is reviewing these items particularly. All approvals will be noted in the Board meeting minutes. The list of journal entries viewed during the meeting will be initialed by a Board member and kept on file as documentation of internal controls.

View Audit 408352

Finding 1225392 (2025-003)

Material Weakness 2025

Harrington Family Health Center

ME

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was app...

Finding: 2025-003 Condition Found: During testing of a statistically valid sample of 19 patient accounts that received sliding fee discounts, 2 patient files did not contain eligibility documentation to support that the patients qualified for the sliding fee discount at the time the discount was applied Individual(s) Responsible for Corrective Action: Chief Executive Officer, Fractional CFO, Billing Team Planned Corrective Action: The Organization revised its sliding fee discount policies, implemented centralized documentation tracking, and enhanced staff training related to eligibility determination and documentation requirements. Monitoring procedures, including periodic supervisory review, were established to ensure compliance. Anticipated Completion Date: Implemented and in progress. Due to the timing of the prior year’s audit completion, the Organization did not have time to complete a full monitoring cycle prior to audit testing.

View Audit 408346

Corrective Action Plans

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