Corrective Action Plans

Finding 1206074 (2024-001)

Material Weakness 2024

NC

Internal Control / Segregation of Duties

Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by p...

Corrective Action: The duties will be separated as much as possible and alternative controls will continue to be used to compensate for lack of separation. The governing board has become more involved in providing some of these controls. Proposed Completion Date: The Board is remaining involved by providing authorization and monitoring controls on a regular and timely basis.

View Audit 397984

Finding 1206066 (2024-003)

Material Weakness 2024

Boulder City Hospital, Inc.

NV

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

Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently f...

Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2024, the Hospital should have USDA debt reserves at least equal to $459,326. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

View Audit 397947

Finding 1205859 (2024-003)

Material Weakness 2024

Juneau Housing First Collaborative

AK

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Special Tests & Provisions § 200.326

2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and cer...

2024-003 – Significant Deficiency in Internal Control over Compliance and Other Matters – Special Tests and Provisions Name of Contact Person: Mariya Lovishchuk, Development Director Corrective Action: This was a clerical error issue. Davis Bacon Wages were paid throughout the entire project and certified payroll was provided. However, the original construction contract did not include the correct prevailing wage language. Prevailing wages requirement was discussed and agreed upon prior to issuance of contract, but wrong language was inserted by mistake. Upon discovery of the wrong language, contract amendment was immediately issued to rectify. Proposed Completion Date: Already complete

View Audit 397618

Finding 1205811 (2024-004)

Material Weakness 2024

City of Tower, Minnesota

MN

Internal Control / Segregation of Duties

Management will research and clean up the old outstanding items, create a new general ledger account and reconcile all accounts on a monthly basis.

View Audit 397558

Finding 1205810 (2024-003)

Material Weakness 2024

City of Tower, Minnesota

MN

Reporting Internal Control / Segregation of Duties

Management will evaluate the cost benefit of making cash to accrual adjusting entries on an annual basis.

View Audit 397558

Finding 1205809 (2024-002)

Material Weakness 2024

City of Tower, Minnesota

MN

Internal Control / Segregation of Duties

Management is aware of the finding and has concluded that it is not economically feasible to correct this finding. Management will rely on oversight by the Mayor and City Council to monitor this condition.

View Audit 397558

Finding 1205808 (2024-001)

Material Weakness 2024

City of Tower, Minnesota

MN

Internal Control / Segregation of Duties

For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements an...

For now, the City accepts the degree of risk associated with this condition and thoroughly reviews a draft of the financial statements, footnote disclosures, and supplementary information prior to issuance. Management will engage the audit firm to prepare drafts of its annual financial statements and related footnote disclosures in accordance with the regulatory basis of accounting.

View Audit 397558

Finding 1205800 (2024-001)

Material Weakness 2024

Town of Akron

CO

Material Weakness Internal Control / Segregation of Duties

The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.

View Audit 397536

Finding 1205742 (2024-005)

Material Weakness 2024

Excelsior Springs Hospital

MO

Reporting Internal Control / Segregation of Duties

Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.

View Audit 397466

Finding 1205047 (2024-001)

Material Weakness 2024

Detroit Police Athletic League, Inc.

MI

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

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...

Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.

View Audit 396692

Finding 1205007 (2024-002)

Material Weakness 2024

Innovative Health Solutions

CA

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements

View Audit 396668

Finding 1205006 (2024-001)

Material Weakness 2024

Innovative Health Solutions

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...

Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.

View Audit 396668

Finding 1205000 (2024-010)

Material Weakness 2024

The City of Frederick, Maryland

MD

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...

Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.

View Audit 396662

Finding 1204855 (2024-004)

Material Weakness 2024

Mountain State Centers for Independent Living, Inc.

WV

Internal Control / Segregation of Duties

Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statem...

Indirect cost proposal. MSCIL acknowledges the need to maintain compliance wi th fed eral reporting requirements and has taken steps to ensure timely submission going forward. Management will complete and submit the indirect cost proposal immediately upon finalization of the audited financial statements. Responsibility for preparing future proposals will be assigned to a designated staff member, with oversight from the President/CEO to ensure deadlines are met. MSCIL is also refining its reporting schedule and review procedures to support timely and accurate filings in future years. The Fyffe Jones Group will assist with filing needs as necessary to support compliance and ensure accuracy of submissions. These steps will help e nsure tha t indirect cost proposals are submitted timely in accordance with federal requirements.

View Audit 396485

Finding 1203053 (2024-001)

Material Weakness 2024

Incorporated Village of Ocean Beach

NY

Procurement, Suspension & Debarment Cash Management Matching / Level of Effort / Earmarking § 200.303

United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will wor...

United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will work on updating all policies and procedures relating to the U.S. Office of Management and Budget Uniform Guidance to ensure the Village policies are in compliance with these guidelines. Responsible Contact Person: Linda M. Morrisey Village Treasurer Village of Ocean Beach Bay & Cottage Walks, P.O. Box 457 Ocean Beach, NY 11770 Anticipation completion date: March 31, 2026

View Audit 396283

Finding 1191626 (2024-001)

Material Weakness 2024

Hawkeye Properties and Workforce Innovation, Inc.

CA

Reporting Internal Control / Segregation of Duties § 200.510 § 200.512

Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Feder...

Management has taken steps to contract an audit firm and is currently working with the auditors to perform the single audit for the fiscal year ended June 30, 2025, with anticipation of completion before the deadline of March 31, 2026. Management has also prepared a Schedule of Expenditures of Federal Awards for the fiscal year ended June 30, 2025.

View Audit 395484

Finding 1191602 (2024-003)

Material Weakness 2024

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 interna...

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 395458

Finding 1191113 (2024-002)

Material Weakness 2024

Keams Canyon Elementary School

AZ

Internal Control / Segregation of Duties

The School has hired a consultant for training.

View Audit 395263

Finding 1191112 (2024-001)

Material Weakness 2024

Keams Canyon Elementary School

AZ

Reporting Internal Control / Segregation of Duties

The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.

View Audit 395263

Finding 1190872 (2024-001)

Material Weakness 2024

St. John's Lutheran Home of Albert Lea

MN

Material Weakness Reporting Internal Control / Segregation of Duties

St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2...

St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2024. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2023 – September 30, 2024 The findings from the September 30, 2024 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2024-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Heather King, Director of Finance, 507-473-1066 Anticipated Completion Date: Ongoing

View Audit 395160

Finding 1182298 (2024-005)

Material Weakness 2024

The Order of Fishermen Ministry Head Start Program, Inc.

MI

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immedi...

TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immediately filed. The Agency will prepare a checklist of required federal reports by the finance department, which will be monitored by the Program Director. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025

View Audit 393724

Finding 1182294 (2024-003)

Material Weakness 2024

The Order of Fishermen Ministry Head Start Program, Inc.

MI

Subrecipient Monitoring Material Weakness Reporting § 200.501 § 200.512 § 200.514

TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audi...

TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audit process and submit the data collection report within the required time period. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025

View Audit 393724

Finding 1181995 (2024-004)

Material Weakness 2024

Village of La Valle

WI

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

2024-004 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants...

2024-004 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The Village does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal awards is high. Auditor’s Recommendation: We recommend that the Village works on written policies and procedures over grants and grant expenditures. Management Response: The Village will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance.

View Audit 393368

Finding 1181955 (2024-003)

Material Weakness 2024

Western Prairie Human Services

MN

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.303

Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly repo...

Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly reports are completed two fiscal staff will have reviewed the chart of accounts codes. Anticipated Completion Date: 1/31/2025

View Audit 393258

Finding 1181906 (2024-002)

Material Weakness 2024

Butts County Board of Commissioners

GA

Internal Control / Segregation of Duties

Management will concur with the finding and will establish and implement formal procedures to ensure sufficient and appropriate documentation is obtained and maintained prior to removing a student from the graduation cohort.

View Audit 393207

Corrective Action Plans

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