Corrective Action Plans

Finding 570673 (2024-001)

Significant Deficiency 2024

IN

Special Tests & Provisions Internal Control / Segregation of Duties

Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") ...

Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") system. Recommendation: The Organization should review internal controls over updates to its sliding fee scale each year to ensure it is properly updated. Corrective Action Plan: The organization has updated fees in the electronic medical record and made sure that those match approved nominal fees and will make sure they are in alignment going forward. Contact Person Responsible: Assistant Director of Finance Expected Completion date: June 30, 2025

View Audit 361694

Finding 570663 (2024-004)

Material Weakness 2024

Tuerk House, Inc.

MD

Reporting Internal Control / Segregation of Duties

Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has in...

Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has initiated corrective actions to improve internal controls over financial and programmatic reporting. These actions include: ·Establishing a standardized reconciliation process to ensure that all amounts reported in financial reports are tied directly to supporting documentation from the general ledger and other internal financial systems. ·Implementing a dual-review protocol requiring reports to be reviewed and approved by both finance and program staff before submission to funding agencies. · Providing targeted training to relevant personnel on grant reporting requirements, with an emphasis on reporting accuracy, documentation standards, and deadlines. ·Coordinating regular meetings between finance and program departments to align data and ensure consistency between financial and programmatic reporting (e.g., patient counts, service metrics, etc.). ·Developing a reporting calendar to track all reporting requirements and facilitate timely and accurate submissions. We are committed to ensuring accurate and compliant reporting going forward and will monitor implementation closely to prevent recurrence. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025

View Audit 361681

Finding 570637 (2024-005)

Material Weakness 2024

The Mirror, Inc.

KS

Eligibility Internal Control / Segregation of Duties

Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. ...

Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.

View Audit 361664

Finding 570636 (2024-004)

Material Weakness 2024

The Mirror, Inc.

KS

Reporting Internal Control / Segregation of Duties

Plan: • Implementing new work flows around grants being awarded. Ensuring all grants are tracked in a single location with identifications within the spreadsheet to track federal awards. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO will review ...

Plan: • Implementing new work flows around grants being awarded. Ensuring all grants are tracked in a single location with identifications within the spreadsheet to track federal awards. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO will review staffs entries on the spreadsheet to ensure necessary data/information for each grant is being kept, in order to have a SEFA prepared for each audit.

View Audit 361664

Finding 570633 (2024-001)

Material Weakness 2024

The Mirror, Inc.

KS

Procurement, Suspension & Debarment Equipment & Real Property Management Internal Control / Segregation of Duties

Plan: • The accounting team will implement processes to review and reconcile the cash and investment account quarterly. • The depreciation schedule will be maintained more accurately each month. Additional training will be provided to AP Clerk whom enters assets into the module. • Prepaid expense...

Plan: • The accounting team will implement processes to review and reconcile the cash and investment account quarterly. • The depreciation schedule will be maintained more accurately each month. Additional training will be provided to AP Clerk whom enters assets into the module. • Prepaid expenses will be reconciled monthly by AP Clerk and reviewed quarterly by the CFO. • Accrued payroll liabilities will be adjusted to supporting documentation at the end of each fiscal year. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO, will have overall responsibility and will perform the validation and review of these reconciliations.

View Audit 361664

Finding 570615 (2024-001)

Material Weakness 2024

Scott County Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Cash Management

Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are n...

Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are not receiving enough funding to cover the expenses for our program. Currently, we are working with our Field Representative, Wilma Henry and Finance Management, Lin Wang to release our reserves to resolve this issue.

View Audit 361639 Questioned Costs: $1

Finding 570581 (2024-004)

Significant Deficiency 2024

Boys & Girls Clubs of Northeast Ohio

OH

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

BGCNEO corrected the overbilling in June and July before the grant period closed. BGCNEO will have stronger controls around the grant period year ends to ensure double billings are less likely to occur.

View Audit 361612 Questioned Costs: $1

Finding 570580 (2024-003)

Significant Deficiency 2024

Boys & Girls Clubs of Northeast Ohio

OH

Internal Control / Segregation of Duties

BGCNEO will utilize controls within the payroll system to increase employee responsibility and place more emphasis on supervisor review responsibilities. Supervisors will be offered additional training by the administration staff during the year.

View Audit 361612

Finding 570563 (2024-001)

Material Weakness 2024

City of Rialto

CA

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

Reference Number: 2024-001- Timeliness of Financial Reporting (Material Weakness/Material Noncompliance) Name of Contact Person: Janet Franco, Principal Budget and Financial Analyst or Scott Williams, Director of Finance Corrective Action: The City acknowledges that the financial inform...

Reference Number: 2024-001- Timeliness of Financial Reporting (Material Weakness/Material Noncompliance) Name of Contact Person: Janet Franco, Principal Budget and Financial Analyst or Scott Williams, Director of Finance Corrective Action: The City acknowledges that the financial information and documentation, including the trial balance, was not prepared in a timely manner. This prevented the auditors from completing the audit, and the Single Audit, by March 31, 2025. The implementation of the new financial software system, which went live on July 1, 2023, necessitated almost all of the Finance Department’s staff hours to be allocated to ensuring the software system was accurate in its financial reporting. This allocation of resources prevented the City from producing timely financial information. The Finance Department also had the loss of key staff in the department that added difficulty in providing necessary items in a timely manner. The Finance Department has corrected all of the financial and reporting issues that arose in the Summer and Fall of 2024 and is also working on fully staffing the department to be able to complete reporting in timely manner. The Finance staff has reviewed and updated its procedures for closing the financial records for the 2023-24 fiscal year, and has already begun the process of closing the books for 2024-25. The City fully expects to file the financial audit in a timely manner for the 2024-25 fiscal year. Proposed Completion Date: Fiscal Year ended June 30, 2025.

View Audit 361591

Finding 570562 (2024-001)

Material Weakness 2024

City of Cleburne, Texas

TX

HUD Housing Programs Special Tests & Provisions Subrecipient Monitoring

Section III. Findings and Questioned Costs for Federal Awards Item 2024-001 Assistance Listing Numbers: 14.871 – Housing Voucher Cluster Federal Agency: U.S. Department of Housing and Urban Development Pass-through Entity: N/A Type of Finding: Material Weakness in Internal Control over Compliance an...

Section III. Findings and Questioned Costs for Federal Awards Item 2024-001 Assistance Listing Numbers: 14.871 – Housing Voucher Cluster Federal Agency: U.S. Department of Housing and Urban Development Pass-through Entity: N/A Type of Finding: Material Weakness in Internal Control over Compliance and Noncompliance Compliance Requirement: Special Tests and Provisions Questioned Costs: None Criteria 24 CFR 982.305(a) requires that grantees must inspect housing units at least biennially, and annually per their Housing Administrative Plan, to determine whether housing units meet Housing Quality Standards. 2 CFR 200 requires that internal control over compliance be established to provide reasonable assurance for compliance. Condition During our audit testing, we haphazardly selected a sample of 40 tenants to determine if the admission criteria were met. Of those 40 tenants, we identified 7 instances where an inspection was not conducted on an annual basis. Cause The City’s established procedures did not include sufficient controls to ensure that the criteria were met in accordance with policy and regulation before the housing assistance payments were authorized. Effect The City was not in compliance with these program requirements. Recommendation We recommend that management strengthen controls to ensure that housing assistance payments are not authorized before the required criteria are met. Ideally, this would include changes to the authorization process that prevent authorization from being made without the review having been completed. Management’s Response 131 Management acknowledges the audit finding related to Material Weakness in Internal Control over Compliance and Noncompliance for 14.841 – Housing Voucher Cluster. We agree with the assessment and recognize the importance of addressing the underlying issue to enhance the organization's operations and internal controls. To resolve this issue, the City has already implemented staffing changes aimed at addressing this material weakness and better program management for housing These changes include the hiring of Terrence Hamilton. Terrence comes to the City with a strong background in housing and has already implemented structural changes to address housing division needs. Management is confident that the hiring of Terrence and the support for his actions have effectively remediated the material weakness and will help prevent similar issues in the future. We remain committed to maintaining strong internal controls and will continue to monitor the effectiveness of these changes regularly. Person responsible for corrective action: Terrence Hamilton Anticipated completion date: May 31, 2025

View Audit 361587

Finding 570554 (2024-005)

None 2024

City of Shepherdsville

KY

Reporting Internal Control / Segregation of Duties

The City has retained a consultant to clean up old data, and we are commi􀆩ed to closing the books by August 31, 2025. As a result of improving our processes and 􀆟ghtening internal controls, we can begin our audit process much sooner than in prior years and have all aspects of the audit completed 􀆟me...

The City has retained a consultant to clean up old data, and we are commi􀆩ed to closing the books by August 31, 2025. As a result of improving our processes and 􀆟ghtening internal controls, we can begin our audit process much sooner than in prior years and have all aspects of the audit completed 􀆟mely. This will be overseen by the Finance Director.

View Audit 361571

Finding 570549 (2024-002)

Material Weakness 2024

Whitley County

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Scott Wagner Contact Phone Number: 260-248-3121 Ext 5 swagner@whitleygov.com Views of Responsible Official: We concur with the finding. Descrip...

FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Scott Wagner Contact Phone Number: 260-248-3121 Ext 5 swagner@whitleygov.com Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Whitley County Health Department has developed and implemented a policy that will establish and maintain effective internal control for invoices for State and Federal Grants received by the Department. The Director of the department will review all compiled data and sign the invoice along with the employee who compiled the invoice data. In cases where the Director is the employee compiling the data, the office administrator will also sign the invoice to verify the data is correct. Anticipated Completion Date: Immediately

View Audit 361558

Finding 570547 (2024-002)

Significant Deficiency 2024

Public Health - Madison and Dane County

WI

HUD Housing Programs Equipment & Real Property Management Internal Control / Segregation of Duties

Finding 2024-002 Condition / Context One unit tested did not have an inspection completed within the last two years, and another unit tested did not have adequate support that the inspection was completed. Our sample was statistically valid. Corrective Action Plan Corrective Action Planned: On a...

Finding 2024-002 Condition / Context One unit tested did not have an inspection completed within the last two years, and another unit tested did not have adequate support that the inspection was completed. Our sample was statistically valid. Corrective Action Plan Corrective Action Planned: On a monthly schedule, management will review Annual HQS Inspections Report that is part of the Section Eight Management Assessment Program (SEMAP) Indicators Report generated from Inventory Management System/PIH Information Center (PIC) submissions and follow up with inspectors regarding units with incomplete information of final inspection within the last 25 months, the acceptable timeline per U.S Department of Housing and Urban Development (HUD) guidelines. By year end, CDA will train staff and fully implement the use of Emphasys HQS Mobile to schedule, complete and store reports electronically, improving internal controls of tracking inspection completion. Name(s) of Contact Person(s) Responsible for Corrective Action: Sadie Villegas - Client Services Manager Anticipated Completion Date: December 31, 2025

View Audit 361547

Finding 570520 (2024-001)

Material Weakness 2024

Village of Streamwood

IL

Cash Management Reporting Internal Control / Segregation of Duties

Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Corrective Action Plan: The Village and Finance Director will implement internal controls to properly record capital assets on a t...

Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct capital assets that were improperly recorded in prior years. Corrective Action Plan: The Village and Finance Director will implement internal controls to properly record capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Josh Peacock, Finance Director Management Response: In conjunction with our auditors, the Village identified certain capital assets that were under the capitalization policy threshold. During 2024, Village staff took the opportunity to clean up (identify and remove) these items which resulted in the restatement. The Village will be more diligent in following the capitalization policy moving forward and do not see this as an area of concern for the foreseeable future.

View Audit 361511

Finding 570519 (2024-001)

None 2024

Anoka County Community Action Program, Inc.

MN

HUD Housing Programs Procurement, Suspension & Debarment Internal Control / Segregation of Duties

Management agrees with the finding and has prepared a corrective action plan to complete these annually.

View Audit 361502

Finding 570505 (2024-001)

Significant Deficiency 2024

Polk County, Florida

FL

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before su...

Department of Homeland Security Hazard Mitigation Grant-Assistance Listing No. 97.039 Recommendation: It was noted that improvements were observed compared to the previous year, however, we advise the County to maintain a review process to ensure quarterly reports are thoroughly examined before submission to FDEM. Additionally, monitoring procedures should be established to guarantee the proper submission of close-out reports. Implementing a technology solution could aid the grant manager in gathering the necessary reports for the grantor, facilitating easier oversight and monitoring of grant compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will further strengthen oversight of programmatic reporting by developing and implementing a system of monitoring procedures to guarantee that periodic reports contain the appropriate data, have an adequate review performed by the relative Division Director, and are submitted within the timeframe required by the funder. The proper submission of close-out reports will also be accomplished through the developed monitoring procedures. A grant management software will be purchased and implemented and become a foundational component of the County's grant management infrastructure, allowing for more effective oversight by the County grant manager and ensuring greater compliance with all applicable regulations. Additionally, the County will implement mandatory trainings focusing on 2 CFR Part 200, to ensure fiscal and project managers involved with grant projects are fully educated on uniform administrative requirements, including proper reporting and close-out procedures, cost principles, and audit requirements related to federal and pass-through awards. Name(s) of the contact person(s) responsible for corrective action: Terri Saltzman, Grants and Community Investment Manager. Planned completion date for corrective action plan: September 30, 2025. If the Department of Homeland Security has questions regarding this plan, please call Terri Saltzman at 863-519-2049.

View Audit 361493

Finding 570501 (2024-002)

Material Weakness 2024

West Central Nebraska Joint Housing Authority

NE

Internal Control / Segregation of Duties Special Tests & Provisions Eligibility

Finding 2024-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the inte...

Finding 2024-002: We agree with the finding. The Authority is relatively small with limited administrative staff. Further, the Board of Commissioners is a volunteer oversight board and not a managing board and does not have the time or expertise to provide the necessary services to correct the internal control deficiencies noted. The Board had reviewed the issue and determined that there are no additional procedures which can be reasonably done to eliminate the deficiencies and accepts them.

View Audit 361476

Finding 570486 (2024-001)

Material Weakness 2024

Community Coalition Against Human Trafficking

TN

Questioned Costs Subrecipient Monitoring Cash Management § 200.403 § 200.430

Management concurs with the recommendation to implement internal controls to ensure all costs charged to the program are accurate, allowable, and properly allocated in accordance with the terms of the federal award, and that there is proper review and approval.

View Audit 361435 Questioned Costs: $1

Finding 570440 (2024-001)

Significant Deficiency 2024

Gulf Coast Heron Housing, INC

FL

HUD Housing Programs Reporting Significant Deficiency

Finding: Under the Uniform Guidance, Section 200.512 Report Submission, the audit must be completed, and the data collection form and single audit package must be submitted to the Federal Audit Clearinghouse (FAC) with the earlier of 30 calendar days after receipt of the auditor's report, or nine mo...

Finding: Under the Uniform Guidance, Section 200.512 Report Submission, the audit must be completed, and the data collection form and single audit package must be submitted to the Federal Audit Clearinghouse (FAC) with the earlier of 30 calendar days after receipt of the auditor's report, or nine months after year end of the audit period. This deadline would have been March 31, 2025, for the Organization's Single Audit reporting for the year ended June 30, 2024. Corrective Action Taken or Planned: Management has reviewed the recommendations and will develop a schedule with auto reminders to ensure that these reporting requirements are completed on a timely basis. The corrective action will be implemented no later than June 30, 2025. The primary designated official is the Chief Financial Officer.

View Audit 361410

Finding 570101 (2024-001)

Significant Deficiency 2024

City of Ely, Minnesota

MN

Internal Control / Segregation of Duties

Finding Number: 2024-001 Name of Contact Person: Harold Langowski, City Clerk-Treasurer Corrective Action Planned: Clerk-Treasurer will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffin...

Finding Number: 2024-001 Name of Contact Person: Harold Langowski, City Clerk-Treasurer Corrective Action Planned: Clerk-Treasurer will attempt to monitor transactions and structure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffing limitations and funding constraints. Anticipated Completion Date: Management has been monitoring transactions and reviewing the duties of office personnel on an ongoing basis.

View Audit 361379

Finding 570077 (2024-028)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions,...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions, including evidential support of timing of submission of required reports such as submission confirmations or logs. These internal controls ensure oversight of reporting requirements that are outsourced to vendors.

View Audit 361368

Finding 570066 (2024-023)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Cash Management § 200.305

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, sta...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, state, and similar types of grants and contracts.

View Audit 361368

Finding 570062 (2024-022)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.302 § 200.329

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to sp...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to specific individuals or departments.

View Audit 361368

Finding 570058 (2024-020)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Cash Management Eligibility § 200.334

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently ...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently reviewed, approved, submitted, retained and retrievable for the required retention period. This includes quarterly reports, expense reimbursement packets submitted to the grantors, project expenditure reports, or other grant-related records necessary to demonstrate compliance with federal reporting and record retention standards under the federal programs.

View Audit 361368

Finding 570038 (2024-006)

Significant Deficiency 2024

Passage Home

NC

Questioned Costs Allowable Costs / Cost Principles Cash Management

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Within 60 days of audit issuance, the Interim CFO will conduct training for finance staff regarding accounts payable invoices and sales tax requirements and coding. Updated accounts payable policies and procedures include a process to ensure that the CFO reviews and codes sales tax when checks are prepared, approved and signed. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 09/30/2025

View Audit 361326 Questioned Costs: $1

Corrective Action Plans

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