Corrective Action Plans

Finding 565054 (2024-003)

Material Weakness 2024

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Item: 2024-003 Assistance Listing Number: 16.812 Program: Second Chance Act Reentry Initiative Federal Agency: U.S. Department of Justice Pass-Through Agencies: Pima County Contract Numbers: CT-BH-21-378 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance wi...

Item: 2024-003 Assistance Listing Number: 16.812 Program: Second Chance Act Reentry Initiative Federal Agency: U.S. Department of Justice Pass-Through Agencies: Pima County Contract Numbers: CT-BH-21-378 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance with the grant agreement, the Organization is required to submit monthly reports to the grantor within 10 days following the end of each month. Condition: For all 4 of the monthly reports tested, the reports were submitted subsequent to the 10th day following the end of each respective month. Name of Contact Person: Ramon Dominguez, CFO Phone Number (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will ensure that monthly reporting for the grant is reviewed and approved in a timely manner in order to meet grant deadlines.

View Audit 358970

Finding 565049 (2024-002)

Material Weakness 2024

Community Bridges, Inc.

AZ

Material Weakness Reporting Internal Control / Segregation of Duties

Item: 2024-002 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Relief Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County, City of Phoenix Contract Numbers: C-22-20-029-3-12, 220141; 157666-005, 159341-0 , 160315-0 Award Ye...

Item: 2024-002 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Relief Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: Maricopa County, City of Phoenix Contract Numbers: C-22-20-029-3-12, 220141; 157666-005, 159341-0 , 160315-0 Award Year: 10/01/2023 – 9/30/2024 Compliance Requirement: Reporting Criteria: In accordance with the grant agreements, the Organization is required to submit monthly program reports for each contract within certain prescribed timeframes. Documentation should be maintained to support that the required reports were submitted to the granting agencies and that the submissions were timely. Condition: For seven reports tested, there was no documentation supporting that the reports were submitted to the granting agencies. Name of Contact Person: Ramon Dominguez, CFO Phone Number (480) 831-7566 x4909 Anticipated Completion Date: September 30, 2025 Views of Responsible Officials and Corrective Actions: The Organization will ensure that documentation of submission of monthly program reporting to granting agencies is maintained.

View Audit 358970

Finding 565012 (2024-001)

Material Weakness 2024

Lapeer County

MI

Questioned Costs Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.317 § 200.318 § 200.327

May 27, 2025 Roslund, Prestage & Company, P.C. 525 W. Warwick Drive, Suite A Alma, MI 48801 Re: Corrective Action Plan Regarding Section III: Schedule of Findings and Questioned Costs for the Fiscal Year Ended September 30, 2024, in Reference to 2024-001 Procurement It was identified in the findings...

May 27, 2025 Roslund, Prestage & Company, P.C. 525 W. Warwick Drive, Suite A Alma, MI 48801 Re: Corrective Action Plan Regarding Section III: Schedule of Findings and Questioned Costs for the Fiscal Year Ended September 30, 2024, in Reference to 2024-001 Procurement It was identified in the findings of 2024-001 Procurement (repeat comment) that LCCMH had not followed proper procurement requirements and procedures regarding the agreement in reference to ALN 93.969 Certified Community Behavioral Health Clinics (CCBHC) expansion Grants. LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Thank you, Brooke Sankiewicz Chief Executive Officer Lapeer County Community Mental Health (810) 667-0500 bsankiewicz lapeercmh.org

View Audit 358880 Questioned Costs: $1

Finding 565002 (2024-002)

Material Weakness 2024

Holland Home

MI

Material Weakness Reporting Internal Control / Segregation of Duties

Condition: The Organization is required to submit a quarterly narrative report within 30 days following the end of the calendar quarter to the granting agency. The Organization submitted the four required reports for the year, however, 3 of the 4 reports were submitted after the required deadline. P...

Condition: The Organization is required to submit a quarterly narrative report within 30 days following the end of the calendar quarter to the granting agency. The Organization submitted the four required reports for the year, however, 3 of the 4 reports were submitted after the required deadline. Planned Corrective Action: Management will update its review process to ensure all required reporting is completed timely. Management has noted that the nature through which the grant was issued resulted in some confusion regarding time periods and critical reporting requirements related to the grant program. Contact person responsible for corrective action: Adam Kinder, CFO Anticipated Completion Date: December 2024 – January 2025

View Audit 358874

Finding 565001 (2024-001)

Material Weakness 2024

Holland Home

MI

Subrecipient Monitoring Material Weakness Reporting

Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient until October 2024. As a result, the Organization did not meet the requirements of performing formal risk assessment p...

Condition: The Organization has engaged a subrecipient as part of this grant program, which was subsequently determined, but did not have an executed agreement with the subrecipient until October 2024. As a result, the Organization did not meet the requirements of performing formal risk assessment procedures prior to engaging with the subrecipient. Planned Corrective Action: Management has executed an agreement with the identified subrecipient and implement formalized policies and procedures to ensure no risk factors for non-compliance exist and to properly monitor the subrecipient activity. The identified subrecipient has met all documentation and submission requirements to support reporting and appropriate usage of grant funds related to the grant program. Contact person responsible for corrective action: Adam Kinder, CFO Anticipated Completion Date: October 2024

View Audit 358874

Finding 564768 (2024-004)

Material Weakness 2024

Unified School District No. 431 Hoisington, Kansas

KS

Cash Management Material Weakness Reporting

MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer ...

MATERIAL WEAKNESS 2024-004 – Education Stabilization Fund - Reporting Condition The quarterly reports had incorrect expenditures reported for the ESSER III award. Recommendation Reporting methods required by the awarding agency should be well understood, and an individual other than the preparer should review all reports prior to their submission. Comments on the Finding The District is aware of the oversight and has implemented procedures to prevent this in the future. Actions Taken As of the date of this notice, an individual other than the one preparing the ESSER reporting will be asked to review it, prior to submission.

View Audit 358831

Finding 564705 (2024-001)

Material Weakness 2024

Heber-Overgaard Unified School District No. 6

AZ

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.512

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Forest Service Schools and Roads Cluster, Education Stabilization Fund Assistance Listing Number: 10.665, 84.425 Contact Person: Andrea Despain, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The ...

Finding Number: 2024‐001 Program Name/Assistance Listing Title: Forest Service Schools and Roads Cluster, Education Stabilization Fund Assistance Listing Number: 10.665, 84.425 Contact Person: Andrea Despain, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District will collaborate with all grant stakeholders to strengthen internal controls by clearly defining responsibilities, tracking submission deadlines, and ensuring strict adherence to policies. Oversight will be reinforced through regular grant management meetings and reviews conducted by the Business Manager. To enhance reporting accuracy and documentation practices, staff will receive targeted training on compliance requirements. Additionally, recordkeeping processes will be standardized, with periodic reviews to verify adherence and improve efficiency. These corrective actions will be implemented promptly and continuously supported through ongoing monitoring, ensuring more timely and accurate audits while maintaining compliance with federal regulations.

View Audit 358807

Finding 564663 (2024-003)

Material Weakness 2024

Pioneer Resources, Inc.

MI

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding 2024-003: MATERIAL WEAKNESS—Transit Services Programs Cluster Payroll Procedures U.S. Department of Transportation Pass-through Entity: Michigan Department of Transportation Assistance Listing Numbers: 20.516 and 20.521 Award Numbers: 215509NI, 215541NI, 220776NI and 221303NI Award Year ...

Finding 2024-003: MATERIAL WEAKNESS—Transit Services Programs Cluster Payroll Procedures U.S. Department of Transportation Pass-through Entity: Michigan Department of Transportation Assistance Listing Numbers: 20.516 and 20.521 Award Numbers: 215509NI, 215541NI, 220776NI and 221303NI Award Year End: September 30, 2024 Recommendation: The Organization should follow its established procedures to ensure that payroll records, including manual and electronic, are properly and timely filed and maintained in accordance with the Organization’s written record retention policy so that they can be readily located when needed. Action Taken: Staff responsible for these tasks will be educated on the importance of following the Organization’s policy. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2025.

View Audit 358795 Questioned Costs: $1

Finding 564659 (2024-003)

Material Weakness 2024

McIntosh Senior Living

MN

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

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing: #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately trac...

Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing: #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked and a documented review and approval over the reserve fund occurred. Responsible Individuals: Sharlene Knutson, Administrator Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2025

View Audit 358780

Finding 564584 (2024-003)

Material Weakness 2024

Goshen Community Schools

IN

School Nutrition Programs Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.303

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Heather Bontrager, Director of Nutrition and Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Descript...

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person Responsible for Corrective Action: Heather Bontrager, Director of Nutrition and Whitney Dixon, Treasurer Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed, Allowable Costs/Cost Principles This finding was limited to payroll claims and payroll vendor disbursements and did not involve accounts payable vendor disbursements. For payroll disbursements, once payroll is processed, a distribution report is sent to the Director of Nutrition to review all employees paid from the Federal Nutrition Program (Fund 0800). The Director communicates any necessary corrections to employee distributions, which are then adjusted by the payroll specialist, if needed. During the audit period, the school corporation experienced a vacancy in the payroll specialist position. As a result, the Treasurer processed payroll and the Deputy Treasurer conducted the reviews. However, the school corporation did not obtain signatures on the payroll reports during this time. The only signed documentation was the ACH report used for the bank upload. Going forward, the school will implement the use of digital signatures whenever possible to document payroll report reviews. For payroll vendor claims, vouchers are generated from the financial system and are signed by both the payroll specialist and the Chief Financial Officer. These signed vouchers are also included on the board docket. Although this process was in place during the audit period, the school corporation did not have a fully effective internal control system to ensure that all payroll reports were consistently signed following review by the Treasurer. Anticipated Completion Date: June 2025

View Audit 358719

Finding 564477 (2024-003)

Material Weakness 2024

Wright County Community Action, Inc.

MN

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

Head Start ‐ ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit findin...

Head Start ‐ ALN #93.600 Recommendation: We recommend that the Organization should review and approve the indirect costs that are allocated by the preparer and retain support of this review and approval. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA has already implemented a process to ensure indirect cost allocations are reviewed and approved with proper documentation. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025

View Audit 358612

Finding 564472 (2024-002)

Material Weakness 2024

Wright County Community Action, Inc.

MN

Material Weakness Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Head Start ‐ ALN #93.600 Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit ...

Head Start ‐ ALN #93.600 Recommendation: We recommend that the assigned individual to review formally documents their review and approval of the reports with a signature before the required date to be submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCCA has already implemented a process to ensure all reports are reviewed and approved with documentation before submission. Name(s) of the contact person(s) responsible for corrective action: Carrie Tripp, Executive Director Planned completion date for corrective action plan: September 30, 2025

View Audit 358612

Finding 564247 (2024-001)

Material Weakness 2024

Metro Towers, Inc. St. James Place

MO

HUD Housing Programs Special Tests & Provisions Procurement, Suspension & Debarment

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2024 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended December 31, 2024. Finding 2024-001 Responsible Party Name: Fred Gibbs Position: President – Management Agent Telephone Number: 913-709-1811 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Purchase or Refinancing of Existing Multifamily Rental Housing (Section 207/223(F)) Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action We will follow our policies and procedures to ensure that accounting records are kept accurate and complete, and a responsible official will review and sign off on the monthly financial statements. Anticipated Completion Date June 30, 2025

View Audit 358353

Finding 564243 (2024-015)

Material Weakness 2024

Charter County of Wayne, Michigan

MI

Eligibility Material Weakness Matching / Level of Effort / Earmarking § 200.303

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal particip...

Condition: The County’s controls over meal participants did not ensure a review was in place to check the intake forms for Halal Home Delivered meal participants or that updated assessments were obtained for home delivered meals. Lastly there was not a control in place to ensure liquid meal participants maintained a physician order, renewed every six months, stating the need for the continued supplement service. Planned Corrective Action: Wayne County’s Department of Senior Services will implement processes to ensure only eligible individuals receive meals. A quarterly report will be run to verify all home delivered meal clients have updated assessments and reassessments and will be reviewed by the Department Director and or Division Director quarterly. Halal home delivered meal clients assessments will be reviewed by a second staff member to ensure eligibility and verified by the Department Director and or Division Director monthly. Contact person responsible for corrective action: Joan Siavrakas, Division Director Anticipated Completion Date: 04/25/2025

View Audit 358351

Finding 564138 (2024-002)

Material Weakness 2024

Myrtle Point School District

OR

Subrecipient Monitoring Reporting Material Weakness § 200.508 § 200.510

Finding 2024-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.5...

Finding 2024-002 - Schedule of Expenditures of Federal Awards (Material Weakness) CFDA Title and Number 10.555 National School Lunch Program cluster Name of Federal Agency: U.S. Department of Agriculture Compliance/Internal Control over Compliance: Auditee Responsibilities Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Expenditures of federal awards and not be detected and corrected. Because the Auditee’s SEFA was completed incorrectly, and not reconciled to the general ledger the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • No reconciliation between federal expenditures reported on the GL and the SEFA was presented. • Recording of State vs Federal activities was not posted to the GL correctly, requiring adjustments during the audit. • Not all grants were recorded in separate and identifiable GL accounts. Repeat of a Prior-Year Finding: Yes Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. City’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: October 1, 2025 Responsible Person: Director of Business Services, Myrtle Point School District No. 41

View Audit 358289

Finding 564129 (2024-003)

Material Weakness 2024

Crooksville Exempted Village School District

OH

Subrecipient Monitoring Material Weakness Reporting § 200.332

The District will thoroughly examine all grant disclosures and requirements, follow guidance provided, and maintain records related to all reporting. Treasurer has communicated that all district expenditure data reporting be completed by Treasurer/CFO in the future.

View Audit 358259

Finding 563968 (2024-001)

Material Weakness 2024

Commonbond Communities

MN

Internal Control / Segregation of Duties Material Weakness Reporting

Corrective action – Management has designed and implemented an improved month end procedure and related review process, it will continue documenting its training program and developing team members, and more fully utilizing the accounting modules in its Enterprise Resource Planning system to add mor...

Corrective action – Management has designed and implemented an improved month end procedure and related review process, it will continue documenting its training program and developing team members, and more fully utilizing the accounting modules in its Enterprise Resource Planning system to add more system-based controls. Name of contact person – Jennifer Anderson, Interim Chief Financial Officer Proposed completion date – Management has begun the corrective action and is expected to have additional processes in place and training done by December 31, 2025.

View Audit 358143

Finding 563872 (2024-002)

Significant Deficiency 2024

Federation of American Scientists

DC

Material Weakness Reporting Internal Control / Segregation of Duties

Identifying Number: 2024-001 Finding: Current management noted that the audited financial statements as of and for the year ended June 30, 2023, were materially misstated for certain contribution transactions recorded in error in the amount of $7,997,654. Those errors were corrected and recorded in...

Identifying Number: 2024-001 Finding: Current management noted that the audited financial statements as of and for the year ended June 30, 2023, were materially misstated for certain contribution transactions recorded in error in the amount of $7,997,654. Those errors were corrected and recorded in fiscal year 2024, which is not in accordance with U.S. GAAP. Corrective Actions Taken or Planned: The entire finance team was new in FY24. During an internal review, management identified that certain revenue transactions had been recorded incorrectly in the prior fiscal year (FY23), resulting in a materially misstated ending balance for FY23 and, consequently, an inaccurate beginning balance for FY24. Because FY23 had already been closed and audited, the necessary corrections were recorded in FY24. Management proactively informed the new auditors of these adjustments. Due to the materiality of the correction, the auditors determined that the FY23 ending balance needed to be reinstated. As a result, they expanded their scope to include a re-audit of FY23 to ensure the accuracy of the reinstated balances, which extended the overall audit timeline. It’s important to emphasize that this finding was self-identified and communicated by management, and the correction was properly recorded in FY24. No further corrective action is required for FY25. Throughout FY24, the finance team has worked diligently to strengthen internal policies, processes, controls, and systems, which contributed to a clean audit result for FY24. This finding relates solely to FY23 and does not reflect the current state of financial management. Name of Responsible Person: Manizha Nabieva, CFO Projected Date of Completion: 05/28/2025 Identifying Number: 2024-002 Finding: Federation of American Scientists’ fiscal year 2024 data collection form was not submitted within nine months after the end of the audit period. Corrective Actions Taken or Planned: The delay in filing the data collection form was directly related to the delay in finalizing the audit, as noted in the first finding above. Since this was our first year working with RSM, the audit scope expanded significantly due to the reinstatement of beginning balances. The auditors required additional time to ensure the accuracy of the financial statements before issuing their final report. We will finalize and submit the data collection form as soon as the audit is complete, but no later than May 28, 2025. To prevent similar delays in the future, we have already initiated discussions with our auditors regarding the FY25 audit and plan to begin the audit process in October 2025. Name of Responsible Person: Manizha Nabieva, CFO Projected Date of Completion: 5/28/2025

View Audit 358091

Finding 563835 (2024-002)

Material Weakness 2024

Oslc Developments, Inc.

OR

Reporting Subrecipient Monitoring Material Weakness § 200.502

Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and ar...

Recommendation: We recommend the organization revisit its policies and procedures surrounding management’s review of grant and other contractual agreements to ensure all federal assistance, including subawards, are properly identified as such at the time the agreements are signed or received, and are properly included on the SEFA. ODI agrees with the auditors’ recommendation. Consistent with response to finding 2024-001, we have reviewed the design and implementation of internal controls procedures around accounting for grants and contracts. This has resulted in revision of our new funding form including identifying federal and nonfederal designations in subcontracts from states, and determination of conditions to ensure compliance with U.S. GAAP. Responsible staff member, Laurie Larson-Lewis, Finance Manager, completion date 5/31/2025.

View Audit 358060

Finding 563814 (2024-004)

Material Weakness 2024

Waimanalo Health Center

HI

Special Tests & Provisions Eligibility Material Weakness

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Speci...

Health Resources and Services Administration Mary Frances Oneha, Waimanalo Health Center’s CEO respectfully submits the following corrective action plan for the year ended June 30, 2024: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2024Item 2024-004 - Special Tests and Provisions (Material Weakness) During our audit, we noted that the Center did not properly determine the sliding fee discount of certain eligible patients based on information provided during the patient registration process. Recommendation We recommend that the Center conduct training of all of its personnel who are involved in determining the sliding fee scale of patients. We also recommend that an internal audit of a sample of patient charts be conducted periodically to ensure that patients' sliding fee scale discounts or category is properly and accurately determined based on information provided by patients. Finally, we recommend that such internal audit be documented. Action Taken Management agrees with the finding and will be establishing policies and procedures and conducting training for all personnel involved in determining patients' sliding fee scale to help ensure the accuracy of the process. Management will also implement an internal audit of a sample of patient charts and will ensure that such audits are properly documented. Effectivity Date: June 30, 2025

View Audit 358045

Finding 563799 (2024-002)

Material Weakness 2024

Wallingford Housing Authority

CT

Reporting HUD Housing Programs Material Weakness

Finding Reference Number: 2024-002 Reporting Description of Finding: The required unaudited annual filing with HUD's Real Estate Assessment Center (REAC), for fiscal 2024, was not made by the required deadline of September 15, 2024. In addition, as noted in finding 2024-001, prior audit adjustments...

Finding Reference Number: 2024-002 Reporting Description of Finding: The required unaudited annual filing with HUD's Real Estate Assessment Center (REAC), for fiscal 2024, was not made by the required deadline of September 15, 2024. In addition, as noted in finding 2024-001, prior audit adjustments, there were material misstaments that were not identified and corrected by management. Statement of Concurrence or Nonconcurrence: The Wallingford Housing Authority agrees and accepts the above referenced findings. Corrective Action: The Wallingford Housing Authority currently is procuring a new third-party fee accountant that will prepare and submit all required unfilled filings to the appropriate agencies. The Wallingford Housing Authority will create and maintain a schedule of all required submittal dates.

View Audit 358012

Finding 563613 (2024-002)

Material Weakness 2024

Council of Spanish Speaking Organizations, Inc.

PA

Allowable Costs / Cost Principles Student Financial Aid Subrecipient Monitoring

2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of H...

2024-002 • Material Weakness in Internal Control over Compliance Condition: During our eligibility assessment, we examined 40 files from Community Umbrella Agency 3 (CUA) foster care children to ensure they contained required documents by the City of Philadelphia and Pennsylvania's Department of Human Services (DHS). Our review found missing documents, time gaps between submissions, or untimely paperwork, including the following: (a) 29 CUA Safety Assessments, (b) 30 CUA Safety Plans, (c) 7 CUA PA Model Risk Assessments, (d) 3 CUA Documented Client Visits (Structure Case Notes), (e) FAST Family Advocacy Forms, (f) 17 Life Skills Assessment/ Biopsychosocial Evaluation/ IEP or Ages & Stages Questionnaire (ASQ), (g) 11 School Aged Report Cards, (h) 6 CUA Authorization to Release Information, (i) 9 CUA Immunizations, (j) 3 DHS Court Order Sheets, (k) 14 Child’s Photo, (l) 10 Initial CUA Single Case Plan, (m) 7 Monthly Updates to CUA Single Case Plan, (n) 17 Initial CUA Case Service Conference Summary Report, and (o) 16 Six Month Ongoing CUA Services Conference Summary Report. Furthermore, each child's file needed to contain specific documents from the DHS, which had to be supplied by the department or shown evidence of request by the CUA. Missing documents consisted of: (a) 34 DHS Service Authorization Forms, (b) 21 DHS CUA Provider Referral Forms, and (c) 30 DHS CUA In-Home Services Referral Forms. Recommendation: We recommend that management continue to develop policies and procedures in order to properly include all pertinent documentation within each client file as required by the City of Philadelphia, Department of Human Services. In addition, we recommend that program leadership and/or quality control department performs periodic audits of the client files to ensure all required documentation is included. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. FINDINGS – FEDERAL AWARD PROGRAM AUDITS (CONTINUED) Action taken in response to finding: 1. Hiring of Chief Compliance Officer to oversee Concilio Quality Assurance and Compliance process 2. Staffing of Quality Assurance department 3. Monthly review of client files for accuracy and completeness 4. Additional training of staff to review audit findings and implement corrective action Name of the contact person responsible for corrective action: Albert Essilfie, Chief Financial Officer albert.essilfie@elconcilio.net (215) 627-3100 Planned completion date for corrective action plan: June 30, 2025

View Audit 357894

Finding 563033 (2024-027)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Material Weakness Period of Performance § 200.302 § 200.303

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department contin...

Finding 2024-027 U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Programs Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-023 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

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Finding 562904 (2024-023)

Material Weakness 2024

City of Baltimore, Maryland

MD

Subrecipient Monitoring Eligibility Material Weakness § 200.302 § 200.303

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to rev...

Finding 2024-023 U.S. Department of Health and Human Services AL No. 93.778 Medical Assistance Program (Medicaid; Title XIX) Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-019 Auditee’s Corrective Action Plan: BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established a Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

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Finding 562864 (2024-021)

Material Weakness 2024

City of Baltimore, Maryland

MD

Reporting Subrecipient Monitoring Material Weakness § 200.302 § 200.303

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumu...

Finding 2024-021 U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Reporting Repeat Finding: Yes; 2023-016 Auditee’s Corrective Action Plan: The Federal Financial Report (FFR) is a cumulative report covering the entire project or award period, which for this grant spans from March 1, 2020, to February 28, 2025. As a result, the cumulative amounts reported on the FFR will not align with the amounts recorded in the general ledger for fiscal year 2024. BCHD fiscal department continues to revise its internal processes to strengthen capacity and to ensure compliance with 2 CFR 200 by implementing the following: A. Comprehensive staff training, supported by documented Standard Operating Procedures, training guides and updated policies which will include processes for timely submission of grant reports with required fiscal approvals. B. Create a standard reconciliation process that will ensure expenditures reported on required grantor reports are properly reflected in the general ledger in addition to clearly identifying variances from the SEFA due to timing. C. Created an internal comprehensive grants tracker via Smartsheet which includes all grant award periods, reporting requirements, due dates and other pertinent grant award data. D. Established the Contract and Compliance Unit responsible for overseeing the filing of the FFATA report. Contact Person: Unyime Ekpa, Chief Financial Officer, Baltimore City Health Department Completion Date: September 30, 2025

View Audit 357839

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