Corrective Action Plans

Finding 1211147 (2023-003)

Material Weakness 2023

Carestl Health

MO

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303

"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Pe...

"Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations"

View Audit 400354

Finding 1211146 (2023-002)

Material Weakness 2023

Carestl Health

MO

Internal Control / Segregation of Duties Questioned Costs Cash Management

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...

Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.

View Audit 400354

Finding 1211145 (2023-001)

Material Weakness 2023

Carestl Health

MO

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Questioned Costs § 200.303 § 200.328 § 200.329

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...

Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.

View Audit 400354

Finding 1210598 (2023-007)

Material Weakness 2023

The Salvation Army Golden State Division

CA

Material Weakness School Nutrition Programs Equipment & Real Property Management

The Division will ensure the documentation related to inventory counts are maintained. September 2026 Al Agpoon, Golden State Division Controller

View Audit 399931

Finding 1210578 (2023-006)

Material Weakness 2023

The Salvation Army Golden State Division

CA

Subrecipient Monitoring Eligibility Questioned Costs

The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify they meet the grant eligibility requirements. September 2026 Al Agpoon, Golden State Division Controller

View Audit 399931

Finding 1210558 (2023-005)

Material Weakness 2023

The Salvation Army Golden State Division

CA

Questioned Costs Subrecipient Monitoring Material Weakness § 200.502

The Division will take steps to ensure that proper evidence of review is maintained for the food distribution records and the sign in sheets. September 2026 Al Agpoon, Golden State Division Controller

View Audit 399931

Finding 1206687 (2023-006)

Material Weakness 2023

Homeless Resource Council of the Sierras

CA

Subrecipient Monitoring Cash Management Material Weakness

The Organization agrees with the audit finding. There were gaps in information flow due to staff turnover. The Organization already has a process in place to maintain documentation in a logical manner with adequate access.

View Audit 398809

Finding 1206508 (2023-008)

Material Weakness 2023

MacOmb County

MI

Questioned Costs Material Weakness Reporting § 200.501 § 200.512 § 200.514

The County acknowledges the deficiency in internal controls over financial reporting. The transition to the Workday ERP system in 2023 resulted in delays and challenges in producing timely and accurate financial data. The County is strengthening reconciliation and review processes while continuing t...

The County acknowledges the deficiency in internal controls over financial reporting. The transition to the Workday ERP system in 2023 resulted in delays and challenges in producing timely and accurate financial data. The County is strengthening reconciliation and review processes while continuing to refine system functionality and staff proficiency. Although the 2024 audit represents the first full year in the new system, some delays have continued. The County expects processes to stabilize and reporting timelines to improve, with full resolution anticipated in the 2025 audit cycle.

View Audit 398574

Finding 1206355 (2023-006)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

HUD Housing Programs Special Tests & Provisions Eligibility

Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of...

Special Tests and Provisions - Waiting List Public and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were admitted i nto the Public Housing Program. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. As a result, we were unable to verify that applicants were admitted in accordance with HUD waiting list and tenant selection requirements. Auditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and admission into the program. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's ACOP, i mplement supervisory review controls to verify completeness of waiting list documentation prior to tenant admission, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain tasks in YARDI software, i ncluding waitlist selection. We believe that the error rate will decrease in future years from 2023. In addition, between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that maintain waitlists or perform waitlist selection to reiterate the proper documentations of how to maintain records that demonstrate waitlist positions, selection order and proper selection. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026

View Audit 398376

Finding 1206354 (2023-005)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

HUD Housing Programs Questioned Costs Eligibility

Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were m...

Eligibility P ublic and Indian Housing - ALN 14.850 Material Weakness in Internal Controls Material Noncompliance Condition: Out of an approximate population of 2,150 tenants from the Public and Indian Housing program, we tested 43 tenants and the following deficiencies were noted: • 16 files were missing a flat rent option form, • 14 files were missing 214 forms, • 10 units did not have the required inspection performed, • 9 files had incorrect income or missing income support, • 8 files incorrectly contained prior year information in the current year recertification, • 6 files were missing valid 9886 forms, • 2 files were missing identification for adults in the household, and • 1 file was missing birth certificate or other documentation for minors receiving income credits. A uditor Recommendations: The Authority should reevaluate their established procedures and controls in place to ensure full compliance in regards to eligibility and the timeliness of recertifications. The Authority needs to correct the deficiencies noted in the tested files and consider the impact to the rest of the population of tenant files that were not selected as part of the auditor's sample. Action Taken: HACM's Lease and Compliance department has done additional training with their staff since 2023 on Occupancy, Eligibility, Income and Rent Calculation. In addition, the Director has provided additional onboarding training to new employees and has provided YARDI Aspire training in how to perform certain eligibility tasks in YARDI. We believe that the error rate will decrease in future years from 2023. In add ition,between March 2026 and June 2026, the Lease and Compliance Director will work with all staff that perform initial eligibility or recertifications to reiterate the major topics that HACM has had deficiencies and the proper way to treat those items. Name of Responsible Person: Marquetta Treadway, Lease and Compliance Director Projected Completion Date: June 30, 2026

View Audit 398376

Finding 1206353 (2023-004)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

Special Tests & Provisions Questioned Costs Eligibility

2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenan...

2023-004 Special Tests and Provisions - Waiting List Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: During our audit, we noted that the Authority was unable to provide complete and adequate waiting list documentation to support the selection of tenants who were issued housing vouchers. Specifically, required records demonstrating waiting list position, selection order, and eligibility determinations were not available for review. In addition, 8 of the 40 new admissions tested lacked support for the auditor to complete testing in this area. A uditor Recommendations: We recommend that management perform a reconciliation of the waiting list and reconstruct missing documentation where possible to support applicant selection and voucher issuance. Management should update and formalize waiting list procedures in accordance with HUD regulations and the Authority's Administrative Plan, i mplement supervisory review controls to verify completeness of waiting list documentation prior to voucher issuance, and ensure records are retained in accordance with HUD and federal record-retention requirements. In addition, management should provide training to staff responsible for waiting list administration to promote consistent compliance with HUD requirements. Action Taken: On the same note and based on a HUD review of operations, HACM entered into a SEMAP Corrective Action Plan with HUD with the goal to improve the SEMAP performance indicator scores. Via a nationwide Request for Proposal, HACM hired the contractor, CVR Associates, Inc. (CVR) to manage and operate the entire Housing Choice Voucher program for HACM, effective January 2, 2025. This contract is currently overseen by the Acting Secretary- Executive Director and will be overseen by the Chief Operations Officer once a new one is hired. CVR was selected as the contractor in part due to their extensive experience in managing similar voucher programs nationwide and on their tools/software that they have developed to manage items, such as quality control testing in the areas such as the items noted above. This included wait list oversight and wait list selection. CVR provided additional training to staff, prepared new standard operating procedures i ncluding those over waiting lists, and perform quality control testing over the course of the entire year. Many of the SEMAP indicators have improved, but some have additional improvement still needed based on the 2025 SEMAP results. When there a re issues, the CVR Quality Control team follows up with the staff person to correct the issue, and to provide guidance or additional training with the goal to reduce the error rate in the future. We believe that HACM will be back to being a standard performer or higher in 2026. In addition, the self-reported 2025 SEMAP testing was showing good scores in the area of Waiting List. Name of Responsible Person: Ken Barbeau, Acting Secretary-Executive Director; Chief Operations Officer (once hired); Projected Completion Date: December 31, 2026

View Audit 398376

Finding 1206351 (2023-003)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

HUD Housing Programs Internal Control / Segregation of Duties Questioned Costs

Special Tests and Provisions - SEMAP Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: The Authority was under Troubled Status with HUD for its Housing Choice Voucher program during the 2023 fiscal year. There were multiple fi ndings from HUD with a Cor...

Special Tests and Provisions - SEMAP Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: The Authority was under Troubled Status with HUD for its Housing Choice Voucher program during the 2023 fiscal year. There were multiple fi ndings from HUD with a Corrective Action Plan implemented covering areas typically monitored through SEMAP self-assessment process. A uditor Recommendations: The Authority should evaluate and update its internal control policies and procedures related to HCV compliance requirements. The Authority should continue to work on its Corrective Action Plan with HUD to move out of Troubled Status. Action Taken: On the same note and based on a HUD review of operations, HACM entered into a SEMAP Corrective Action Plan with HUD with the goal to improve the SEMAP performance indicator scores. Via a nationwide Request for Proposal, HACM hired the contractor, CVR Associates, Inc. (CVR) to manage and operate the entire Housing Choice Voucher program for HACM, effective January 2, 2025. This contract is currently overseen by the Acting Secretary- Executive Director and will be overseen by the Chief Operations Officer once a new one is hired. CVR was selected as the contractor in part due to their extensive experience in m anaging similar voucher programs nationwide and on their tools/software that they have developed to manage items, such as quality control testing in the areas such as the items n oted above. CVR provided additional training to staff, prepared new standard operating procedures, a nd perform quality control testing over the course of the entire year. Many of the SEMAP indicators have improved, but some have additional improvement still needed based on the 2025 SEMAP results. When there are issues, the CVR Quality Control team follows up with the staff person to correct the issue, and to provide guidance or additional training with the goal to reduce the error rate in the future. We believe that HACM will be back to being a standard performer or higher in 2026. Name of Responsible Person: Ken Barbeau, Acting Secretary-Executive Director; Chief Operations Officer (once hired); Projected Completion Date: December 31, 2026

View Audit 398376

Finding 1206277 (2023-006)

Material Weakness 2023

Aneta Homes Inc.

ND

Internal Control / Segregation of Duties Questioned Costs Material Weakness § 200.512

Contact Person Terry Hanson Corrective Action Plan The Program will implement procedures to ensure timely reporting for future report submissions. Planned Completion Date for CAP July 31, 2026

View Audit 398305

Finding 1206275 (2023-005)

Material Weakness 2023

Aneta Homes Inc.

ND

Questioned Costs Material Weakness Reporting

Contact Person Terry Hanson Corrective Action Plan The Program will implement procedures to ensure timely reporting for future report submissions. Planned Completion Date for CAP July 30, 2026

View Audit 398305

Finding 1206273 (2023-004)

Material Weakness 2023

Aneta Homes Inc.

ND

Questioned Costs Material Weakness

Contact Person Terry Hanson Corrective Action Plan The Program is aware of required monthly deposits to a reserve for replacement account in accordance with their regulatory agreement. Management will allow for cash flows in to account as allowable. Planned Completion Date for CAP Ongoing

View Audit 398305

Finding 1206099 (2023-001)

Material Weakness 2023

Future Ready Five

OH

Material Weakness Reporting Internal Control / Segregation of Duties

Reference Number: 2023-01 Finding Type: Material Weakness in Internal Control Over Financial Reporting Description of Finding: The Organization’s system of internal controls was not sufficiently designed or implemented to ensure that account reconciliations were prepared on an accrual basis and revi...

Reference Number: 2023-01 Finding Type: Material Weakness in Internal Control Over Financial Reporting Description of Finding: The Organization’s system of internal controls was not sufficiently designed or implemented to ensure that account reconciliations were prepared on an accrual basis and reviewed in a timely and accurate manner. As a result, material audit adjustments were proposed and made to correct misstatements in the financial statements prior to issuance. The deficiencies resulted from inadequate formalized close procedures, limited supervisory review during the year-end closing process, and staffing changes within the accounting function. Weaknesses in year-end close procedures increase the risk that material misstatements could occur and not be identified or corrected on a timely basis, resulting in delayed financial reporting and increased audit effort. Statement of Concurrence: Management agrees with the finding. Corrective Action: Future Ready Five (FR5) hired Maureen Thomas, Chief Financial Officer, in September 2024 and since then formal monthly and year-end close procedures in accordance with accrual accounting have been implemented, which include supervisory review to ensure accurate and timely financial reporting. The Finance Committee meets bi-monthly to review the monthly financial statements. Completion Date: January 2025 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org

View Audit 398055

Finding 1191756 (2023-005)

Material Weakness 2023

VALLEY CITY PUBLIC SCHOOL DISTRICT

ND

Questioned Costs Material Weakness Reporting

2022-005 Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2026

View Audit 395557

Finding 1182013 (2023-001)

Material Weakness 2023

Voices of Tomorrow

WA

Allowable Costs / Cost Principles Material Weakness

Voices of Tomorrow will strengthen its payroll and time-and-effort documentation practices to comply with 2 CFR 200.430(i). The Organization will implement an after-thefact time and effort reporting process that accurately reflects actual work performed by employees whose compensation is charged to ...

Voices of Tomorrow will strengthen its payroll and time-and-effort documentation practices to comply with 2 CFR 200.430(i). The Organization will implement an after-thefact time and effort reporting process that accurately reflects actual work performed by employees whose compensation is charged to federal programs.

View Audit 393387

Finding 1181662 (2023-004)

Material Weakness 2023

Maryland Network Against Domestic Violence, INC

MD

Questioned Costs Subrecipient Monitoring Material Weakness

Summary of Finding The Organization did not submit reports timely for three out of three reports tested (100%). This is considered to be a material weakness to the reporting compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-004. Statistical ...

Summary of Finding The Organization did not submit reports timely for three out of three reports tested (100%). This is considered to be a material weakness to the reporting compliance requirement and is a repeat finding shown in Section IV of this report as prior year finding 2023-004. Statistical sampling was not used in making sample selections. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-004. Due to staff turnover and the limited capacity of agency staff and contractors, MNADV has been late in grant reporting. Corrective Action Long-Term Corrective Action: To address the pattern of late reports, the organization has elected to move financial reporting to a quarterly basis whenever the grant award allows as opposed to monthly to reduce the number of required reports. Also, the executive director has elected to train additional staff on programmatic grant reporting in an effort to increase capacity. These two measures will effectively address the problem of late reporting. Responsible Parties: Executive Director, Deputy Director and Contractual Bookkeeper Completion Date: These measures were put into place starting with FY25 which began on October 1, 2024.

View Audit 392932

Finding 1181380 (2023-004)

Material Weakness 2023

California Institute of Environmental Studies

CA

Reporting Subrecipient Monitoring Material Weakness § 200.328 § 200.329

2023-004 Financial Reporting Requirements Recommendation: Auditors recommend that CIES modify its internal control policies for general review and approval of the reporting requirements set forth by the criteria listed. Criteria: 2 CIR 200.328 – Unless otherwise approved by OMB, the Federal awarding...

2023-004 Financial Reporting Requirements Recommendation: Auditors recommend that CIES modify its internal control policies for general review and approval of the reporting requirements set forth by the criteria listed. Criteria: 2 CIR 200.328 – Unless otherwise approved by OMB, the Federal awarding agency must solicit only the OMB-approved governmentwide data elements for collection of financial information (at time of publication the Federal Financial Report) or such future OMB approved, governmentwide data elements available from the OMB designated standards lead. This information must be collected with the frequency required by the terms and conditions of the Federal award, but no less frequently than annually nor more frequently than quarterly except in unusual circumstances, for example where more frequent reporting is necessary for the effective monitoring of the Federal award or could significantly affect program outcomes, and preferably in coordination with performance reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: CIES will implement a process whereby financial information required to be reported to the Federal awarding agency will be prepared by CIES administrative staff (i.e., Administrative Assistant, Chief Operations Officer) and reviewed and approved before submittal by the Executive Director. The review and approval process will be documented and stored within CIES internal electronic files, as appropriate, for each fiscal year. Name(s) of the contact person(s) responsible for corrective action: Michael Parker, Executive Director Planned completion date for corrective action plan: March 2026

View Audit 392629

Finding 1179668 (2023-005)

Material Weakness 2023

Lake County

IN

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

FINDING 2023-005 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan As this finding is shared between T...

FINDING 2023-005 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan As this finding is shared between The Lake County Board of Commissioners and the Lake County Parks & Recreation Department, both departments will develop and implement a proper system of internal controls and segregation of duties. This will ensure accuracy and correctness of all quarterly P & E Reports in the future. Completion Date: June 2026

View Audit 392081

Finding 1179665 (2023-003)

Material Weakness 2023

Lake County

IN

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303 § 200.308 § 200.403

FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the f...

FINDING 2023-003 Finding Subject: COVID-19 Emergency Rental Assistance Program - Period of Performance Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding with reservations on a portion of the Finding. Description of Corrective Action Plan: \ This program is completed and the period of performance is over therefore there is not a need to formally adopt any Corrective Action Plan. The Subrecipient Contractor that administered the program has agreed that this finding was due to their internal error in submitting administration invoices too late to be properly processed and approved by the County. They will be reimbursing the ERA1 fund for the error in the amount of $154,812.56 that will be sent back to the US Treasury. Reservation: The US Treasury required the local grant recipient to prosecute ERA1 fraud activities. There were two fraud cases that were prosecuted by our local attorney. His fees were then deducted from the ERA1 fund as administration costs. The grant recipient should not be penalized for doing as directed to prosecute fraud cases without being able to pay for the services rendered. We do not control the timelines of the local courts nor the responses/actions of the defendants delaying the actions beyond the Period of Performance. Anticipated Completion Date: None, no corrective action plan is necessary.

View Audit 392081

Finding 1179664 (2023-002)

Material Weakness 2023

Lake County

IN

Cash Management Matching / Level of Effort / Earmarking HUD Housing Programs § 200.1 § 200.302 § 200.303

FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Descriptio...

FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This same finding was part of the 2022 audit in Finding 2022-003. The department was aware that this same finding would be arising in the 2023 audit again due to multiple year errors of previous staff. The corrective action plan proposed and adopted as part of the Corrective Action Plan for finding 2022-003 is still in force and is working to eliminate such findings in the future. The Lake County Redevelopment Commission adopted Resolution 001-2025 on January 16th, 2025 amending the Policy and Procedures Manual of the Department concerning Program Income (PI) internal controls for proper reporting in the IDIS system to address and correct the finding going forward. Anticipated Completion Date: Done

View Audit 392081

Finding 1177692 (2023-001)

Material Weakness 2023

Alameda County Deputy Sheriff's Activities League Inc.

CA

Material Weakness Reporting Internal Control / Segregation of Duties

Late Submission of the Single Audit - (Material Weakness) - Repeated (Prior Year Finding 2022-002): Management's Response: Management acknowledges the ﬁnding related to the late submission of the SF-SAC Single Audit Data Collection Form for the year ended June 30, 2023. The delay was primarily attri...

Late Submission of the Single Audit - (Material Weakness) - Repeated (Prior Year Finding 2022-002): Management's Response: Management acknowledges the ﬁnding related to the late submission of the SF-SAC Single Audit Data Collection Form for the year ended June 30, 2023. The delay was primarily attributable to a period of signiﬁcant organizational transition, including major management changes and a downsizing of the organization, which substantially constrained internal capacity during the audit and reporting period. As a result, certain required information necessary to complete the Single Audit was not available within the required timeframe. Management recognizes the importance of timely Single Audit submission and the impact of late ﬁling on the organization’s low-risk auditee status. To remediate this issue, management has implemented corrective actions to strengthen planning and oversight of the audit process, including establishing earlier internal deadlines for year-end close activities, improving cross-functional coordination for audit deliverables, and engaging auditors earlier following year end. Management has also implemented a formal tracking process to monitor Single Audit milestones and submission deadlines to ensure timely ﬁling with the Federal Audit Clearinghouse going forward. Estimated Completion Date: Management expects these corrective actions to be eﬀective beginning with the single audit for the ﬁscal year ending June 30, 2024. Responsible Party: Accounting Manager

View Audit 391109

Finding 1176972 (2023-006)

Material Weakness 2023

Papa Ola Lokahi

HI

Cash Management Material Weakness § 200.305

Views of Responsible Officials and Planned Corrective Action The Organization notes the following existing internal control practices, as it relates to cash management subsequent policy and process development and implementation, and the additional controls to be implemented: A. System, Process & Re...

Views of Responsible Officials and Planned Corrective Action The Organization notes the following existing internal control practices, as it relates to cash management subsequent policy and process development and implementation, and the additional controls to be implemented: A. System, Process & Review Controls In Practice. 1. System Controls. The Organization operates in an environment in which system, process & review controls of the United States Department of Health and Human Services (HHS) are practiced in processing cash (draw) transactions in both the Electronic Handbook (EHB) and Payment Management System (PMS) systems, operated by HHS. Only the director of administrative operations and the CEO have system access to the EHB and PMS systems. 2. Process & Review Controls – EHB & PMS. Cash management requests (aka federal draws) are computed by, and entered into the EHB, including the Organization’s justification of the expenditure, by the director of administrative operations, including the CEO on the approval request. The propriety of the cash draw is reviewed by the HHS assigned grants management specialist; and inquiry action, if needed, documented by e-mail from the grants management specialist; and approval documented in the EHB. Once the draw is approved, the director of administrative operations enters information into the PMS, noting that the CEO, is the authorized organization representative (AOR). The grants management specialist must then approve the draw request once more in the PMS system before a PMS representative approves the draw request. 3. Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls include review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds – Additional Information and Statistics, Native Hawaiian Health Program (Fund 007V), and Native Hawaiian Health Scholarship Program (Fund 017V). B. Internal Control Environment Policy Establishment – July 2025. In July 2025, the Organization developed the following cash management related policies and related procedures: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; Implementation of HRSA Related Policies, including cash management processes and procedures. C. Additional Process & Review Controls – March 2026. Beginning March 2026, for federal draws, process and review internal controls will be implemented, via the chief of staff’s review of the director of administrative operations cash management analyses, federal grant receivable composition, reconciliation and related federal grant revenue computations, prior to any director of administrative operations and chief executive officer action in EHB and PMS, respectively.

View Audit 390799

Corrective Action Plans

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