Corrective Action Plans

Finding 1237943 (2025-003)

Material Weakness 2025

City of Vincennes

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Activities Allowed or Unallowed Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Offici...

FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Activities Allowed or Unallowed Contact Person Responsible for Corrective Action: Catherine MM Lane Contact Phone Number and Email Address: 812-882-6426 clane@vincennes.in.gov Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: The Clerk-Treasurer’s office will prepare APV for all claims, including those related to payroll benefits. The APVs will be included on the claims docket which will be presented to the City Council for their review and approval. Additionally, the Clerk-Treasurer will certify each claim prior to payment. Anticipated Completion Date: The corrective action plan will be implemented by December 31, 2026.

View Audit 412721

Finding 1237766 (2025-003)

Material Weakness 2025

SPRINGFIELD TOWNSHIP BOARD OF TRUSTEES

OH

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.302 § 200.328 § 200.329

If we receive federal funds in the future, we will stay abreast of current and changing policies and procedures.

View Audit 412681

Finding 1237734 (2025-003)

Material Weakness 2025

St. Vincent De Paul Village, Inc.

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.306

Finding Number 2025-003: Matching – Significant Deficiency in Internal Control over Compliance and Noncompliance Corrective Action: Management will update its matching procedures to require staff to verify that each cost is allowable under the applicable grant before including it in the matching poo...

Finding Number 2025-003: Matching – Significant Deficiency in Internal Control over Compliance and Noncompliance Corrective Action: Management will update its matching procedures to require staff to verify that each cost is allowable under the applicable grant before including it in the matching pool. The procedures will specifically exclude unrecovered indirect costs from CoC Program match unless HUD provides prior written approval. Grant accounting staff will retain support for each matching cost, and a supervisor will review and approve the matching schedule before submission. Any ineligible costs identified will be removed and corrected. Name of Responsible Individual(s): Jason Brenier and Judy Bokhari Anticipated Completion Date: December 2026

View Audit 412640

Finding 1237674 (2025-003)

Material Weakness 2025

Contemporary Oriental Medicine Foundation

FL

Special Tests & Provisions Student Financial Aid Subrecipient Monitoring

Finding 2025-003: Late Refunds- Student Financial Assistance Cluster - Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: The Department of Education requires that all refunds be made within 45 days of a student’s withdrawal (34 CFR 668.22, 685.306). Condition: Sikic...

Finding 2025-003: Late Refunds- Student Financial Assistance Cluster - Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: The Department of Education requires that all refunds be made within 45 days of a student’s withdrawal (34 CFR 668.22, 685.306). Condition: Sikich tested four drop students in our sample and noted two late refunds. This finding is considered to be a material weakness and an instance of noncompliance. This finding was not a repeat finding. Recommendation: We recommend the College increase controls over monitoring drop students and paying refunds. Responsible Person: Dr. Jessica Fritz, Bridgette McGuire, Denise Land, DJ Kramer, Derrick Phillips Corrective Action Plan: DRCOM has implemented increased controls over the R2T4 process through increased and timely communication between various departments involved in the drop process and LOA’s. These departments are the Academic Dean, Registrar, Financial Aid, IT, and Student Accounts Implementation Date: 08/01/2026

View Audit 412608

Finding 1237673 (2025-002)

Material Weakness 2025

Contemporary Oriental Medicine Foundation

FL

Special Tests & Provisions Student Financial Aid Material Weakness

Finding 2025-002: Financial Responsibility - Student Financial Assistance Cluster - Federal Direct Student Loans - ALN # 84.268 - Year Ended December 31, 2025 Criteria: An accredited school that participates in Federal programs authorized by Title IV of the Higher Education Act of 1965 is required t...

Finding 2025-002: Financial Responsibility - Student Financial Assistance Cluster - Federal Direct Student Loans - ALN # 84.268 - Year Ended December 31, 2025 Criteria: An accredited school that participates in Federal programs authorized by Title IV of the Higher Education Act of 1965 is required to demonstrate minimum standards of financial responsibility set forth by the U.S. Department of Education (DOE). Condition: The College did not meet the minimum Composite Score set forth by the U.S. Department of Education for the year ended December 31, 2025. We consider this finding to be a material weakness and an instance of noncompliance. This finding is repeated and was reported in the prior year as Finding 2024-002. Recommendation: The College needs to monitor its financial responsibility ratios throughout the year. Responsible Person: Dorian G. Kramer, DJ Kramer, Jennifer Hogan Corrective Action Plan: The college continues to monitor its financial responsibility ratios through the aforementioned financial accountability plans. As well, DRCOM has continued to improve its financial soundness through 2026 through multiple approaches, including a professional third-party assessment and plan implementation for increasing admissions, restructuring of debt, donor recruitment, hiring of a new clinic manager to increase income in the student clinic, and exploring other revenue streams for the college Implementation Date: Overall plan has been in place since 08/2024, with a reassessment of all strategies at the beginning of each semester.

View Audit 412608

Finding 1237669 (2025-001)

Material Weakness 2025

The Carle Foundation

IL

Student Financial Aid Matching / Level of Effort / Earmarking § 200.303

Following the NSC security breach and incorrect institution linking, the College worked with NSC to restore the correct connection, which was resolved in November 2023. The Registrar redeveloped reporting queries and resumed accurate submissions in June 2024. Enhanced processes now allow files to be...

Following the NSC security breach and incorrect institution linking, the College worked with NSC to restore the correct connection, which was resolved in November 2023. The Registrar redeveloped reporting queries and resumed accurate submissions in June 2024. Enhanced processes now allow files to be reviewed, corrected, and finalized within approximately one week, and all reporting was brought current by the end of 2025.

View Audit 412597

Finding 1237658 (2025-002)

Material Weakness 2025

Uniontown Housing Authority

AL

Allowable Costs / Cost Principles Reporting Matching / Level of Effort / Earmarking

2025-002 – ALN 10.415 – Rural Rental Housing Loan – Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Erika Turner, Executive Director Projected Com...

2025-002 – ALN 10.415 – Rural Rental Housing Loan – Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Erika Turner, Executive Director Projected Completion Date: December 31, 2026

View Audit 412578

Finding 1237657 (2025-001)

Material Weakness 2025

Uniontown Housing Authority

AL

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

2025-001 – ALN 10.415 – Rural Rental Housing Loan – Special Tests and Provisions – Replacement Reserve & Reserve Withdrawals Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction...

2025-001 – ALN 10.415 – Rural Rental Housing Loan – Special Tests and Provisions – Replacement Reserve & Reserve Withdrawals Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Erika Turner, Executive Director Projected Completion Date: December 31, 2026

View Audit 412578

Finding 1237654 (2025-006)

Material Weakness 2025

Aitkin County

MN

Subrecipient Monitoring Eligibility Significant Deficiency

MEDICAL ASSISTANCE - LACK OF CASEFILE CONTROLS Recommendation: It is recommended the County implement formal internal review procedures over casefiles to ensure required procedures are completed and adequately documented. Explanation of disagreement with audit finding: There is no disagreement with ...

MEDICAL ASSISTANCE - LACK OF CASEFILE CONTROLS Recommendation: It is recommended the County implement formal internal review procedures over casefiles to ensure required procedures are completed and adequately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures over casefiles to ensure required procedures are completed and adequately documented. Name of the contact person responsible for corrective action plan: Kathleen Ryan, County: Auditor Planned completion date for corrective action plan: December 31, 2026

View Audit 412568

Finding 1237635 (2025-002)

Material Weakness 2025

Southwest Health and Human Services

MN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.318

Finding Number: 2025-002 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Tiffany Bailey – Fiscal Manager Corrective Action Planned: The planned correctiv...

Finding Number: 2025-002 Finding Title: Procurement Policy Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Tiffany Bailey – Fiscal Manager Corrective Action Planned: The planned corrective action is to improve and update the agency policy for procurement that ensures the required federal components are met. Anticipated Completion Date: December 31, 2026

View Audit 412560

Finding 1237569 (2025-001)

Material Weakness 2025

Mount Horeb Area Joint Fire Department

WI

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

Finding 2025-001 Repeat of finding 2024-001 Condition There was not a review/approval performed of the annual reserve deposit tested and its entry for the loan. The sample was not statistically valid Corrective Action Plan Corrective Action Planned: The control deficiency has been discussed with the...

Finding 2025-001 Repeat of finding 2024-001 Condition There was not a review/approval performed of the annual reserve deposit tested and its entry for the loan. The sample was not statistically valid Corrective Action Plan Corrective Action Planned: The control deficiency has been discussed with the Department’s management and we acknowledge our responsibility for a review and approval process. The Board was aware that this condition existed and realizes that the concentration of duties and responsibilities in a limited number of individuals is not desirable from a control point of view. The Department is now using our Fire Board Treasurer to review and confirm deposits and account balances for our USDA loan and reserve payments. This provides an additional, objective layer of duty separation for our financial work. This position is currently held by Mark Eastman from the Town of Perry, who is not part of our in-house management team. Mr. Eastman signed a written statement certifying his review for FY2026. As part of a broader separation of duties strategy, the Department now employs a Business Manager. This role has access to our QuickBooks accounting software to review all transactions, balances, and journal entries, with a directive to escalate any discrepancies found. Name of Contact Person Responsible for Corrective Action: Jenny Minter, Fire Chief Anticipated Completion Date: January 1, 2026

View Audit 412512

Finding 1237524 (2025-005)

Material Weakness 2025

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New inco...

Corrective Action Plan: All files for the House of Joseph Residence are now reviewed on a quarterly basis by the case manager and the program director, and a checklist has been created so that case managers can confirm that all necessary documents are contained within a given client’s file. New income certifications, which are part of the checklist for documents that need to be in a client’s file, have been completed as well and the two files lacking documentation to support the annual income reported by the tenant have been corrected. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Corrections were completed in August 2026.

View Audit 412475

Finding 1237523 (2025-004)

Material Weakness 2025

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was wo...

Corrective Action Plan: The Organization had discovered the issue of one of the tenants of House of Joseph Residence exceeding 30% of the area median income when we assisted him in applying for Medicaid in early 2026, for which he was initially denied due to income. The individual in question was working part-time, and we had him scale back his working hours accordingly so that in the future he would not exceed the threshold of the 30% area median income going forward and eventually qualify for Medicaid. We also emphasized with the tenant the consequences of exceeding the 30% limit as well. Contact Person Responsible for Corrective Action: Eugene Halus (COO), John Bates (Deputy Director, Programs), and Eugene Watson (Program Manager) Anticipated Completion Date of Corrective Action: Completed in early 2026.

View Audit 412475

Finding 1237464 (2025-005)

Material Weakness 2025

Hearts for the Invisible Charlotte Coalition

NC

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

Auditor’s Recommendation: It is recommended that the Organization consistently implement and document the review and approval controls established by its policies, including continued Board/Treasurer oversight over expenditures. It is also recommended that the Organization continue use of formal tim...

Auditor’s Recommendation: It is recommended that the Organization consistently implement and document the review and approval controls established by its policies, including continued Board/Treasurer oversight over expenditures. It is also recommended that the Organization continue use of formal timesheets to document and support employee time. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and agrees with the recommendation. The Organization implemented Board/Treasurer oversight during the middle of 2025 and formal timesheets effective October 27, 2025. Management will continue to maintain documented review and approval controls and utilize formal timesheets to support payroll activity.

View Audit 412412

Finding 1236929 (2025-003)

Material Weakness 2025

Warrick County

IN

Internal Control / Segregation of Duties Material Weakness Period of Performance § 200.1 § 200.303

Finding Subject: 2025-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Debbie Bennett-Stearsman Contact Phone Number and Email Address: 812-319-9068 and dbennett-stearsman@warrickcounty.gov View of Responsib...

Finding Subject: 2025-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Debbie Bennett-Stearsman Contact Phone Number and Email Address: 812-319-9068 and dbennett-stearsman@warrickcounty.gov View of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: As explained and demonstrated by the County Administrator to the SBOA at the time of the audit, the online reporting system for the U.S. Treasury quarterly reports had malfunctioned. When the County Administrator attempted to enter the correct amounts, the report would be rejected. The only way to get the quarterly reports to be accepted was by adjusting the numbers, resulting in the issues pointed out by the SBOA. As the SBOA is aware, the reports were on a time-sensitive deadline and had to be submitted. The County will follow up with the U.S. Treasury in the event of future problems with the online reporting system. The County Administrator did follow up with the U.S. Treasury in 2025. No response was given. In 2026, the U.S. Treasury provided a webinar stating that if the municipality could not close out or lock awards due to unbalanced figures, then the municipality should leave the project “unlocked.” There was no guidance on reopening previous quarterly reports to correct any mistakes. Therefore, the County Administrator could not correct previous reports. Anticipated Completion Date: September 30, 2026.

View Audit 412381

Finding 1236906 (2025-001)

Material Weakness 2025

Community Directions, Inc.

LA

HUD Housing Programs Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

FINDING #2025-001 SURPLUS CASH Condition: At December 31, 2022 the Entity had surplus cash totaling $9,162, due to Home Funds. Park Ridge Apartments, Phase 3 had surplus cash in the amount of $4,000. Park Ridge Apartments, Phase 4 had surplus cash in the amount of $2,077. Park Ridge Apartments, Phas...

FINDING #2025-001 SURPLUS CASH Condition: At December 31, 2022 the Entity had surplus cash totaling $9,162, due to Home Funds. Park Ridge Apartments, Phase 3 had surplus cash in the amount of $4,000. Park Ridge Apartments, Phase 4 had surplus cash in the amount of $2,077. Park Ridge Apartments, Phase 5 had surplus cash in the amount of $1,379. Parsk Ridge Apartments, Phase 6 had surplus cash in the amount of $1,706. The Entity paid the surplus cash for Park Ridge Apartments, Phase 3 and Phase 6, leaving a balance of $3,456 at December 31, 2024. There were no payments to surplus cash during the current fiscal year. Recommendation: The management agent should compute an estimate of surplus cash for the fiscal year upon completion of that period. In the event that surplus cash exists at the completion of the fiscal period, the management agent should make an installment payment on the HOME note. Views of Responsible Officials and Planned Corrective Action: The management agent agrees with the finding and the auditor’s recommendations have been adopted. Surplus cash will be calculated upon the completion of an annual fiscal period. If it is concluded that surplus cash exists at the end of the annual fiscal period, an installment payment will be made on the loan.

View Audit 412343

Finding 1236900 (2025-001)

Material Weakness 2025

The New York and Presbyterian Hospital

NY

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.403

Finding COVID-19 – 2025-001 Allowable Costs/Cost Principles Information on the federal program: Federal agency: U.S. Department of Homeland Security Pass-through program from: State of New York Division of Homeland Security and Emergency Services Federal Assistance Listing Number: 97.036 COVID-19 Di...

Finding COVID-19 – 2025-001 Allowable Costs/Cost Principles Information on the federal program: Federal agency: U.S. Department of Homeland Security Pass-through program from: State of New York Division of Homeland Security and Emergency Services Federal Assistance Listing Number: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Contract/pass-through entity identifying number: 140215 Award period of performance: January 20, 2020 – July 1, 2022 Planned corrective action: COVID-19-eligible pharmacy costs consisted of a high volume of lower-cost items and were identified through a process distinct from other cost categories. Cost data were obtained from NYP’s materials management system, which records purchase orders placed with primary vendors for medications and supplies. NYP submitted for FEMA reimbursement only those medication costs identified as related to the treatment of patients during the COVID-19 pandemic. Pharmacy vendors may adjust purchase orders when medications or supplies are unavailable or available in quantities different from those requested. The internal control process for the pharmacy portion of NYP’s COVID-19 submissions did not verify that purchase orders were fulfilled as recorded, supported by vendor invoices and receipt documentation, and paid before the associated costs were included in reimbursement claims. Going forward, designated Finance and Pharmacy personnel will reconcile purchase orders to vendor invoices, receipt records, and proof of payment before submission; exceptions will be resolved and documented, and management will periodically review the control’s operation to confirm that only eligible, incurred, and paid costs are claimed. Name of responsible officials: Richard Einwechter Vice President, Financial Operations (212) 585-6589 rie9001@nyp.org Gary Sorkin Vice President Insurance and Risk Management (212) 297-5714 gas9063@nyp.org

View Audit 412335

Finding 1236817 (2025-011)

Material Weakness 2025

Birmingham City Board of Education

AL

Matching / Level of Effort / Earmarking Special Tests & Provisions

The construction projects originated from an initial bid awarded in 2022, which was approved in multiple phases. The original 2022 bid specifications did not include Davis-Bacon Act requirements; consequently the 2023-2024 projects tested during the audit period did not comply with the applicable wa...

The construction projects originated from an initial bid awarded in 2022, which was approved in multiple phases. The original 2022 bid specifications did not include Davis-Bacon Act requirements; consequently the 2023-2024 projects tested during the audit period did not comply with the applicable wage provisions. Going forward, the Board will ensure that all construction projects, either wholly or in part, being paid with federal dollars, will include the Davis-Bacon Act provisions and all related federal compliance requirements in accordance with Title 29.

View Audit 412302

Finding 1236800 (2025-001)

Material Weakness 2025

San Antonio Community Hospital

CA

Allowable Costs / Cost Principles Period of Performance Matching / Level of Effort / Earmarking

Corrective Action Plan Finding 2025-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – May 11, 2025 Summary of Finding: Management did not consistently retai...

Corrective Action Plan Finding 2025-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – May 11, 2025 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management implemented corrective action as of December 31, 2024 to ensure detail approval of individual transactions was retained, however many of the expenditures were from prior years, as allowed for by FEMA, when documentation was not retained, thus the finding is repeating in 2025. Responsible Party: Wah-Chung Hsu, Chief Financial Officer Completed Date: December 31, 2024

View Audit 412285

Finding 1236796 (2025-003)

Material Weakness 2025

City and Borough of Wrangell, Alaska

AK

Reporting Subrecipient Monitoring Significant Deficiency § 200.303 § 200.512

The Borough has implemented procedures to ensure Federal Single Audit requirements are identified, monitored, and completed within required deadlines. Finance staff will maintain a schedule of applicable federal reporting and audit requirements, monitor federal expenditures throughout the fiscal yea...

The Borough has implemented procedures to ensure Federal Single Audit requirements are identified, monitored, and completed within required deadlines. Finance staff will maintain a schedule of applicable federal reporting and audit requirements, monitor federal expenditures throughout the fiscal year, and coordinate with the Borough's auditors to ensure Single Audit requirements are identified and addressed timely. The Finance Director will provide oversight of this process and ensure required documentation and filings are completed within applicable deadlines. These procedures are expected to fully resolve this finding during FY2026. Expected Completion Date: June 30, 2026.

View Audit 412282

Finding 1236681 (2025-101)

Material Weakness 2025

Mayer Domestic Water Improvement District

AZ

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303 § 200.512

Condition and Context: The District did not establish controls to identify and monitor applicable federal reporting requirements associated with its federal awards. As a result, the District did not submit its Single Audit reporting package to the Federal Audit Clearinghouse by the required deadline...

Condition and Context: The District did not establish controls to identify and monitor applicable federal reporting requirements associated with its federal awards. As a result, the District did not submit its Single Audit reporting package to the Federal Audit Clearinghouse by the required deadline of March 31, 2026. Recommendation: The District should establish procedures to identify applicable Federal compliance requirements upon acceptance of Federal awards, monitor cumulative Federal expenditures to determine when a Single Audit is required, assign responsibility for monitoring reporting deadlines, and maintain a compliance calendar to ensure timely submission of all required Federal reports and the Single Audit reporting package. Contact Name: Carrissa Anderson, Business Administrator Corrective Action Planned: The District accepts the recommendation and will improve internal controls over reporting. The District has added this to our annual calendar to ensure proper reporting to the Federal Audit Clearinghouse. Anticipated Completion Date: Immediately.

View Audit 412226

Finding 1236551 (2025-002)

Material Weakness 2025

Douglas County

MN

Eligibility Significant Deficiency Matching / Level of Effort / Earmarking

Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...

Recommendation: ll is recommended County management implements a review process in place to ensure the information added into the METS and MAXIS systems malches supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will add a review process to ensure the casefile eligibility determinations match the supporting documentation provided. Name of the contact person responsible for corrective action plan: Tabitha Kremmin, Community Human Services Director Planned completion date for corrective action ptan: December 31, 2026

View Audit 412094

Finding 1236511 (2025-001)

Material Weakness 2025

City of Whitewater

WI

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties

Assistance Listing Number/Program Title: #66.468/Capitalization Grants for Drinking Water State Revolving Loan Fund Federal Agency/Pass-Through Entity: Environmental Protection Agency/Wisconsin Department of Administration Award Number/Year: 5650-02/2025 Criteria: Proper financial closing and year-e...

Assistance Listing Number/Program Title: #66.468/Capitalization Grants for Drinking Water State Revolving Loan Fund Federal Agency/Pass-Through Entity: Environmental Protection Agency/Wisconsin Department of Administration Award Number/Year: 5650-02/2025 Criteria: Proper financial closing and year-end reconciliation procedures should be in place to identify and adjust the financial records to ensure the financial statements are fairly stated. Condition: The auditors proposed audit adjustments that, if not made, would have resulted in the financial statements being materially misstated. Cause: Financial information was not recorded in a timely manner and material adjustments were needed in order to correct various transactions. Effect: The City’s system of internal control may not prevent, detect, or correct misstatements in the financial statements. Financial reports generated by the accounting system may not provide an accurate reflection of the City’s financial position or activities. Not reconciling accounts on a timely basis could lead to errors or other problems not being recognized and resolved. Recommendation: The auditors recommend that policies and procedures should be implemented to ensure account balances are properly recorded and reconciled in a timely manner. Response: The City acknowledges their responsibility for the financial statements and recording of the current year activity. Going forward, the City will work toward verifying that all activity is completely and accurately recorded in the financial records and reflected on the financial statements. Contact Person: Rachelle Blitch, Finance and Administrative Services Director Anticipated Completion Date: #2025-001 - Ongoing

View Audit 412041

Finding 1236341 (2025-003)

Material Weakness 2025

Community Foundation of Northern Nevada

NV

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Reporting § 200.303

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer ...

Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025

View Audit 412006

Finding 1236327 (2025-001)

Material Weakness 2025

Shalom Health Care Center, Inc.

IN

Special Tests & Provisions Eligibility Significant Deficiency

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the polic...

Significant Deficiency Over Financial Reporting – The following steps have been taken or will be taken to address Finding 2025-001: • Shalom Health Care Center, Inc. has been updated the verbiage in the Sliding Fee Discount Schedule policy and procedures so that the definition of family in the policy better matches the procedures that were being implemented. • Shalom Health Care Center, Inc will be reviewing the updated Sliding Fee Discount Schedule policy and procedures with all employees. • Shalom Health Care Center, Inc will also make sure there is another level of review to make sure that the sliding fee discounts are assigned accordingly based on income and household size. Management did challenge this as being a Significant Deficiency and believes that it should be listed as a note. Management believes additional consideration should be given to the nature, scope, and impact of the exceptions before concluding that the matter constitutes a significant deficiency in compliance with 42 CFR 51c.303(f). The Organization maintained a Board of Directors approve Sliding Fee and Discount Program policy which highlight the family definition and income definition, maintained and annually updated its sliding fee discount schedule in accordance with applicable federal poverty guidelines. The issue identified by the auditors did not involve the design of the discount schedule itself or the incorporation of the federal poverty guidelines. Rather, the exceptions resulted from staff members applying an interpretation of family size that differed from the definition established in the Organization's internal policy when processing individual applications. Accordingly, management believes the audit report should clearly distinguish between an error in applying the Organization's internal methodology and a violation of a federal compliance requirement. Management has requested that the auditors identify the specific provision of 42 CFR 51c.303(f) that was allegedly violated in each of the three cited cases. Management does agree that the procedures did not follow the policy and that this is more of an issue of process and controls. Management respectfully disagrees with the Finding 2025-001, particularly the classification given as a Significant Deficiency and the characterization of the exceptions as noncompliance with the federal requirement cited in the finding. Management requested the auditors to reconsider whether the circumstances support classification as a Significant Deficiency. At a minimum, management requests that the finding clearly distinguish between (1) compliance with the federal requirement and (2) the Organization's internal procedures for determining family size and calculating the sliding fee discount. Based on the limited number of exceptions, the absence of questioned costs, the lack of evidence of intentional noncompliance, and the fact that the Organization maintained and updated its sliding fee schedule in accordance with the applicable poverty guidelines, management believe that the finding should have given a lesser finding classification and a note in the audit report.)

View Audit 411956

Corrective Action Plans

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