Corrective Action Plans

Finding 1160372 (2024-002)

Material Weakness 2024

Detroit Rescue Mission Ministries and Lakeview Farms Missions

MI

Material Weakness Reporting Internal Control / Segregation of Duties

Management has implemented enhanced review processes to ensure accuracy in key accounts and prevent discrepancies. A formal review procedure is now in place to examine journal entries before they are posted.

View Audit 370771

Finding 1160371 (2024-001)

Material Weakness 2024

Detroit Rescue Mission Ministries and Lakeview Farms Missions

MI

Reporting Material Weakness

Management will ensure that the books are closed within 45 days of the end of each reporting period. To support this timeframe, we have put a dedicated team in place. Additionally, a month-end checklist has been established to confirm that all tasks are completed on schedule.

View Audit 370771

Finding 1160329 (2024-003)

Material Weakness 2024

Human Resource Development Institute

IL

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

Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services,...

Finding 2024-003 Material Weakness in Internal Control Over Special Tests and Provisions Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2024 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements.Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. • FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615.

View Audit 370709

Finding 1160328 (2024-002)

Material Weakness 2024

Human Resource Development Institute

IL

Reporting Material Weakness

Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources a...

Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2024 Criteria FFHC is responsible for preparing and submitting its annual Universal Report and Federal Financial Reports in a timely manner. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist.• The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the Federal Financial Reports and the Universal Report. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • To ensure timely submission of Federal Financial Reports (FFR) to HRSA, Friend Health will implement a robust internal calendar that includes all HRSA reporting deadlines along with earlier internal due dates for preparation and review. Designated financial and grants management staff will be responsible for compiling and verifying the required data well in advance of the submission deadline. Friend Health will conduct regular internal reviews to ensure accuracy, completeness, and compliance with HRSA guidelines. Additionally, staff will be provided with ongoing training on HRSA reporting requirements and utilizing reporting tools or software that streamline the FFR preparation process. These proactive measures will help maintain compliance and prevent future delays. • The Organization will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies.

View Audit 370709

Finding 1160276 (2024-002)

Material Weakness 2024

Housing Authority of the County of Chester

PA

HUD Housing Programs Special Tests & Provisions Eligibility

Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertif...

Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertification Timeline • Annual: Start process 120 days before due date. • Interim: Complete within 30 days of household change. • Missed/Delayed: Notify Program Manager immediately and document reason. 2. Required Documentation • Income verification (pay stubs, benefits, child support). • Asset verification (bank/retirement statements). • Family composition docs (birth certificates, SSNs). • HUD-required forms. • Use EIV when available; seek third-party verification first. • All docs must be collected within 60 days of effective date. 3. File Standards • Use Resident File Checklist for each household. • Files must include all signed forms & verifications. • Store in approved secure system (electronic or paper). • Retain files 3 years after end of participation (longer if litigation/audit pending). 4. Internal Controls • Supervisory Review: 10% of files checked monthly. • Maintain clear audit trail (date notices, interviews, verifications). • Correct any deficiencies within 30 days. 5. Staff & Training • Staff handling certifications = annual HUD/HACC compliance training. • Document training completion in personnel file. 6. Monitoring • Quarterly compliance report on timeliness & file completeness. • Issues shared with Executive Director and Board. • Policies reviewed annually for updates. Roles • Housing Specialists: Complete recerts & file docs. • Supervisors: Monitor timeliness & review files. • Compliance Officer: Audit & reporting. • Executive Director: Oversight & resources. n Follow this checklist to ensure timely recertifications, complete documentation, and avoid audit findings.

View Audit 370665

Finding 1160253 (2024-001)

Material Weakness 2024

Methodist Services

PA

Material Weakness § 200.512

Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended June 30, 2023, management was unable to provide timely year end trial balances in accordance with U.S. GAAP without significant adjusting journal entries required to accurately reflect ...

Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended June 30, 2023, management was unable to provide timely year end trial balances in accordance with U.S. GAAP without significant adjusting journal entries required to accurately reflect the underlying accounting transactions. The additional effort needed to reconcile fiscal year 2023 balances resulted in delays in reconciling fiscal year 2024 balances. This finding is was also present in prior year. Recommendation We recommend that individuals overseeing the accounting and finance department continue to review the Organization’s current accounting policies and update existing policies or implement new policies, as needed, to ensure that the trial balances are accurately maintained throughout the year, reconciliations are completed and reviewed monthly or quarterly, as appropriate, and the trial balances and related supporting schedules are prepared and reviewed timely after year-end. Management’s Corrective Action Plan There was significant turnovers in the finance department, including the CFO and the finance director. These turnovers affected the ability of the Organization to produce the information on time for the auditors for the fiscal year 2023 audit. The Organization is working with external consultants to improve the timeliness of reconciliations and audit preparation and recruiting vacant positions. We completed accounting policy changes which will correct the issues noted. Management is confident that the issues that have been noted have been rectified. Contact Person: Cynthia Benton, Chief Financial Officer Anticipated Completion Date: December 31, 2025

View Audit 370632

Finding 1160214 (2024-001)

Material Weakness 2024

Bighorn Valley Health Center, Inc.

WA

Special Tests & Provisions Allowable Costs / Cost Principles Material Weakness

Corrective action planned: In reviewing audit finding 2024-001, it was determined that the primary cause for the misapplication of the sliding fee was the need for increased training and oversight. One Health has since taken steps to enhance sliding fee policy and procedure training for all staff, w...

Corrective action planned: In reviewing audit finding 2024-001, it was determined that the primary cause for the misapplication of the sliding fee was the need for increased training and oversight. One Health has since taken steps to enhance sliding fee policy and procedure training for all staff, with a focus on Intake and Patient Financial Services staff. One Health also intends to review individual performance of staff by implementing peer and supervisory audits of sliding fee scale applications and data entry. Identification of consistent errors has led to enacting accountability measures to allow for additional coaching and follow-up. Additionally, One Health has reviewed EMR processes and functionality to ensure ease and clarity of data entry to eliminate opportunities for human error. Anticipated completion date: December 31, 2025 Contact person responsible for corrective action: Emily Faricy Associate Vice President - Finance

View Audit 370598

Finding 1160193 (2024-019)

Material Weakness 2024

Town of Jonesboro

LA

Internal Control / Segregation of Duties Material Weakness Reporting

The Town of Jonesboro acknowledges this audit finding and concurs that, for the reporting period ending June 30, 2024, performance and financial reports required under the State and Local Fiscal Recovery Funds (SLFRF) program were not submitted to the appropriate oversight authorities nor made avail...

The Town of Jonesboro acknowledges this audit finding and concurs that, for the reporting period ending June 30, 2024, performance and financial reports required under the State and Local Fiscal Recovery Funds (SLFRF) program were not submitted to the appropriate oversight authorities nor made available to the audit team. This lapse was due in part to a lack of understanding of the federal reporting requirements and the absence of internal procedures to track and manage SLFRF reporting obligations. The Town acknowledges that this noncompliance impeded the auditor’s ability to verify program expenditures and compliance with the applicable provisions of 2 CFR Part 200 and guidance issued by the U.S. Department of the Treasury and the Office of Management and Budget (OMB). To correct and prevent future occurrences of this issue, the Town will implement the following corrective action plan: 1. Immediate Remedial Action: The Town will submit any required SLFRF reports for the 2024 program year as soon as possible, even if past the original deadline. We will also reach out to the U.S. Department of the Treasury or its designated agency to formally communicate the reason for the delay and request guidance on next steps, including potential extensions or waivers. 2. Establishment of Formal Reporting Procedures: The Town is developing internal procedures and deadlines to ensure timely submission of all future federal grant reports. These procedures will include: o A reporting calendar with submission deadlines aligned to OMB and Treasury guidance; o Assigned personnel responsibilities for data collection, performance metrics, and narrative preparation; and o Review protocols by finance and grants administration officials prior to submission. 3. Staff Training and Capacity Building: The Town will seek appropriate training from federal or state agencies or through official SLFRF guidance webinars and 116 documentation to ensure staff are fully informed of compliance and reporting responsibilities under the program.

View Audit 370560

Finding 1160190 (2024-016)

Material Weakness 2024

Town of Jonesboro

LA

Procurement, Suspension & Debarment Material Weakness Special Tests & Provisions

The Town of Jonesboro respectfully disagrees with the characterization of this finding. While the Build America, Buy America Act (BABA) has been in effect since November 2021, the Town has not received any prior audit findings or notices of noncompliance related to BABA in previous grant cycles or d...

The Town of Jonesboro respectfully disagrees with the characterization of this finding. While the Build America, Buy America Act (BABA) has been in effect since November 2021, the Town has not received any prior audit findings or notices of noncompliance related to BABA in previous grant cycles or during past administrations. To date, there has been no formal 113 notification or technical assistance provided by federal or state agencies to guide the Town in implementing these requirements in its procurement policies. Nevertheless, the Town fully understands the intent and importance of the BABA provisions, which aim to promote domestic manufacturing and ensure compliance in the use of materials for federally funded infrastructure projects. In light of this finding, the Town will take the following corrective actions: 1. Policy and Procedure Updates: The Town will revise its existing procurement policies to explicitly include compliance requirements for the Build America, Buy America Act, including the use of U.S.-produced iron, steel, manufactured products, and construction materials in all federally funded infrastructure projects. 2. Training and Awareness: Staff involved in procurement, grant administration, and capital infrastructure will undergo appropriate training to ensure a clear understanding of BABA regulations and documentation requirements. The Town will also coordinate with the Louisiana Department of Environmental Quality and the Environmental Protection Agency to obtain relevant training materials and compliance tools. 3. Future Audit Integration: Although the Town has not previously received findings related to BABA, this issue will now be incorporated into internal compliance checklists and future audit procedures to ensure consistent adherence going forward. The Town of Jonesboro is committed to full compliance with federal funding regulations and will implement all necessary improvements to ensure that future federally funded projects align with BABA requirements.

View Audit 370560

Finding 1160189 (2024-015)

Material Weakness 2024

Town of Jonesboro

LA

Questioned Costs Subrecipient Monitoring Cash Management

The Town of Jonesboro respectfully disagrees with this finding as presented. While the audit notes delays between the receipt of federal funds and their disbursement, the Town asserts that it is not responsible for managing or operating the federal financial system that governs the authorization, di...

The Town of Jonesboro respectfully disagrees with this finding as presented. While the audit notes delays between the receipt of federal funds and their disbursement, the Town asserts that it is not responsible for managing or operating the federal financial system that governs the authorization, disbursement, or scheduling of funds related to the referenced grant. The Louisiana Department of Environmental Quality (LDEQ) and other relevant governmental entities manage the disbursement platform used for this grant, and Town personnel do not have direct administrative control over its structure or scheduling capabilities. Furthermore, Town staff have not received adequate training or guidance from state or federal administrators regarding the procedural requirements or compliance timelines for the Clear Water State Revolving Fund (CWSRF) program. Despite these limitations, the Town remains fully committed to compliance with federal cash management standards and the Uniform Guidance (2 CFR § 200.305), which requires recipients to minimize the time elapsing between the receipt and disbursement of federal funds. To that end, the Town will take the following corrective actions: 1. Formal Communication with Program Administrators: The Town will engage the appropriate contacts at the Louisiana Department of Environmental Quality and relevant federal partners to clarify disbursement protocols, timelines, and responsibilities under the CWSRF program. 2. Staff Training and Coordination: The Town will coordinate with the LDEQ and/or EPA to request or arrange formal training for municipal staff involved in the administration of federal grant funds, with a focus on cash management and financial compliance procedures. 3. Procedure Development: Following training and clarification from the funding agencies, the Town will develop internal procedures and documentation protocols to ensure that federal funds are disbursed as promptly as administratively possible upon receipt. The Town of Jonesboro affirms its commitment to fiscal transparency, accountability, and compliance with all applicable state and federal grant management requirements. We look forward to working collaboratively with our state and federal partners to improve administrative performance in all future program years.

View Audit 370560 Questioned Costs: $1

Finding 1160185 (2024-001)

Material Weakness 2024

Saint Joseph Abbey and Seminary College

LA

Material Weakness Reporting Internal Control / Segregation of Duties

Department of Housing and Urban Development Audit firm: Paciera, Gautreau & Priest, LLC, 3209 Ridgelake Drive, Suite 200, Metairie, LA 70002. Audit period: Year ended June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are nu...

Department of Housing and Urban Development Audit firm: Paciera, Gautreau & Priest, LLC, 3209 Ridgelake Drive, Suite 200, Metairie, LA 70002. Audit period: Year ended June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding – Financial Statement Audit: Finding number 2024-001, Material Weakness in Internal Control over Financial Reporting. Condition: The Abbey did not consolidate a subsidiary in its financial statements. Criteria: Generally Accepted Accounting Principles (GAAP) require that all subsidiaries be consolidated into the parent’s financial statements. Cause: The Abbey lacked adequate internal controls to ensure all subsidiaries were identified and consolidated. Effect: The financial statements did not include the financial position and results of operations of the subsidiary. Responsible Person: Right Reverend Gregory Boquet, O.S.B., Abbot Planned Action: Management agrees with the auditor’s finding that there is a material weakness in internal control over financial reporting due to the non-consolidation of a subsidiary. However, after careful consideration, it has been decided not to implement the recommended procedures to consolidate the subsidiary. Justification: Management believes that the current procedures are adequate, and that the non-consolidation of the subsidiary does not materially affect the financial statements. The costs and resources required to implement the recommended procedures outweigh the benefits, given the subsidiary’s limited impact on the overall financial position and results of operations. Management will continue to monitor the situation and reassess it if necessary. Anticipated completion date: Not applicable, as no changes will be made.

View Audit 370555

Finding 1160150 (2024-002)

Material Weakness 2024

Sullivan County

NH

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

2024-002 Improve Controls and Documentation Over Reporting (Material Weakness – Compliance, Internal Control over Compliance) “During our testing of a sample of two of the quarterly expenditure reports utilizing the Governor’s Office for Emergency Relief and Recovery (GOFERR) funding, we noted the f...

2024-002 Improve Controls and Documentation Over Reporting (Material Weakness – Compliance, Internal Control over Compliance) “During our testing of a sample of two of the quarterly expenditure reports utilizing the Governor’s Office for Emergency Relief and Recovery (GOFERR) funding, we noted the following issues: • The Q1 report included $2,534,152 of expenditures that were attributable to a subsequent period as well as a typographical error in the cumulative total expenditure amount; • The Q2 report included $8,636,710 in duplicative expenditures that were also reported in Q1 as well as a typographical error in the cumulative total expenditure amount; and • Formula discrepancies were noted in both Q1 and Q2 reports, resulting in inaccurate calculations. During our testing of the annual project and expenditure report under the direct portion of ARPA funding we noted a material discrepancy between cumulative expenditures per the general ledger and the amount reported of $94,749. The County attributed these discrepancies to a transition to a new summary process designed to increase reporting efficiency. All reported expenditures were valid and appropriately documented based on testing over allowable costs.” Manager’s Statement of Concurrence or Nonconcurrence: The County recognizes there was discrepancy identified between the GOFERR reporting for the ARPA funding and the County’s general ledger. The discrepancy was a result of changes in reporting requirements and data entry errors that did not reflect an actual discrepancy of project costs or missing funds. The issue was used as an opportunity to improve the County’s internal financial tracking by having the Finance Department support the Facilities and Operations Department with an added reconciliation process to verify the reporting is accurate. The reporting requirements have been better clarified since the inception of the reporting model and seems more stabilized. Corrective Action: The worksheet used to track and calculate the data has been updated. Where possible, formulas have been simplified and streamlined to better match the reporting requirements and use corrected timeframes. The remnant data from earlier iterations that catered to earlier requirements, or understanding of those requirements has been removed. When general ledger data entry requests are delivered to the Finance Department they will be accompanied by the worksheet as supporting documentation so that an added reconciliation may be performed.

View Audit 370532

Finding 1160124 (2024-001)

Material Weakness 2024

Mount Vernon School District No. 320

WA

Subrecipient Monitoring Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mou...

Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with federal requirements for allowable activities. Name, address, and telephone of District contact person: Jennifer Larson, Executive Director of Finance 124 E. Lawrence Street Mount Vernon, WA 98273 360-428-6110 Corrective action the auditee plans to take in response to the finding: The district concurs with the finding and has taken corrective action. The employee referenced in the findings is no longer employed by the district. Throughout the months-long investigation performed by OSPI, the district worked to implement changes in our internal controls to ensure strong oversight of Migrant Education Program (MEP) grant compliance, including the eligibility determination process. Changes to internal controls include: • A monthly audit of the families who were visited that month. • A trained program recruiter will conduct the eligibility interviews and home visits. • Recruiter will work with regional trained recruiter for support. • A spot check audit of students determined to be eligible district program director. • Monthly logs from staff identifying students they worked with and services provided. • Monthly meetings between MEP district director and MEP regional program manager to ensure ongoing grant compliance. • Monthly meetings with MEP Parent Advisory Committee for ongoing feedback of services provided. • Appropriate staff including the program director are required to attend Migrant grant training provided by OSPI. We thank OSPI and the Washington State Auditor’s Office for their work and collaboration. We will continue regular monitoring of the Migrant Education Program in the Mount Vernon School district to ensure compliance with all program requirements and only eligible students are being served. Anticipated date to complete the corrective action: August 31, 2025

View Audit 370525

Finding 1159894 (2024-002)

Material Weakness 2024

City of Nashua

NH

Questioned Costs Period of Performance Subrecipient Monitoring § 200.308 § 200.309 § 200.403

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Correcti...

Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Corrective Action: The Nashua School District acknowledges the finding related to the control over the period of performance for federal awards (Finding 2024-002). In response, the district will develop and implement a formal internal procedure to ensure that all purchases funded by federal awards are both placed and received within the established period of performance. This procedure will include appropriate review, documentation, and oversight to maintain compliance with federal grant regulations. To further strengthen internal controls, the Nashua School District will implement a procedure limiting purchases to occur no later than 15 days prior to the grant’s end date. Additionally, all necessary services must be received and completed prior to the expiration of the grant period. Mario Andrade Krystal De Gray Superintendent Chief Operating Officer

View Audit 370436 Questioned Costs: $1

Finding 1159800 (2024-003)

Material Weakness 2024

City of Akron, Ohio

OH

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.

View Audit 370339 Questioned Costs: $1

Finding 1159799 (2024-002)

Material Weakness 2024

City of Akron, Ohio

OH

Subrecipient Monitoring Material Weakness Reporting § 200.208 § 200.328

2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.

View Audit 370339

Finding 1159478 (2024-004)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159472 (2024-002)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are prop...

As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159469 (2024-001)

Material Weakness 2024

North Central Area Agency on Aging, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...

NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.

View Audit 370210

Finding 1159461 (2024-005)

Material Weakness 2024

Wadena County

MN

Allowable Costs / Cost Principles Material Weakness

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has proper controls in place to document the review of all required reports for the program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will enact a process to ensure all reports are received and approved prior to the reporting deadline. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 370195

Finding 1159458 (2024-004)

Material Weakness 2024

Wadena County

MN

Eligibility Allowable Costs / Cost Principles Material Weakness

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: Ther...

Medical Assistance – Assistance Listing No. 93.778 Recommendation: The County should ensure it has controls in place to properly verify assets for cases when required and ensure reviews are being performed consistently with documentation retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure casefiles are reviewed consistently and document that review. Name(s) of the contact person(s) responsible for corrective action: Heather Olson Auditor/Treasurer, Amie Gendron Administrative Services Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 370195

Finding 1159421 (2024-001)

Material Weakness 2024

Brooklyn Plaza Medical Center, Inc.

NY

Special Tests & Provisions Subrecipient Monitoring Eligibility

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...

Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO

View Audit 370146

Finding 1158230 (2024-001)

Material Weakness 2024

New York College of Traditional Chinese Medicine

NY

Student Financial Aid Reporting Special Tests & Provisions

Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Cur...

Finding 2025-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendations: Statement of Concurrence: We concur with the finding of Inaccurate and Untimely Enrollment Status Reporting The inaccuracies and delays were mainly the result of our scheduling process. Currently, we update enrollment maintenance every two months, typically on the day prior to the scheduled dates. We now understand that enrollment status updates must be completed within 15 days after the scheduled date. Actions Taken or Planned: We have reviewed the enrollment maintenance schedule and adjusted our process to ensure compliance with the requirement. Moving forward, enrollment status will be updated within 15 days after the scheduled date. This adjustment will be fully implemented starting from the next scheduled update on 09/30/2025. 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu

View Audit 370123

Finding 1158176 (2024-002)

Material Weakness 2024

Philadelphia Industrial Development Corporation

PA

Internal Control / Segregation of Duties Material Weakness Reporting

2024-002 – Incorrect Filing of Form ED-209 to the EDA Management inaccurately reported balances on Form ED-209 to the EDA. This inaccurate reporting is due to a lack of management review over the reported amounts. Per the ED-209 report, PIDC had $6,048,775 of principal outstanding on loans as of Dec...

2024-002 – Incorrect Filing of Form ED-209 to the EDA Management inaccurately reported balances on Form ED-209 to the EDA. This inaccurate reporting is due to a lack of management review over the reported amounts. Per the ED-209 report, PIDC had $6,048,775 of principal outstanding on loans as of December 31, 2024; however, per the supporting documentation only $5,048,775 of principal outstanding on loans was recorded within the financial statements as of December 31, 2024. Corrective Action During 2024, PIDC initiated an EDA loan to a borrower in the amount of $1,000,000. While the loan was committed at December 31, 2024, the loan was never disbursed. We will establish a dedicated oversight team of existing personnel to monitor the reporting process and to ensure reconciliation of our loan portfolio system. Furthermore, we will streamline our reporting processes by conducting a thorough review and implementing necessary changes. Ongoing training for portfolio management staff on new techniques and software tools will be initiated and continue on a regular basis. Regular progress reviews will be conducted to address quality issues promptly. By implementing these corrective actions, we aim to prevent inaccurate reporting Individual Responsible for Corrective Action Plan Lawrence McComie SVP & Chief Credit Officer 215-496-8145 Anticipated Completion Date: 30 days from issuance, management will file an updated ED-209 report to the EDA.

View Audit 370094

Finding 1158145 (2024-002)

Material Weakness 2024

YMCA of Metropolitan Fort Worth

TX

Material Weakness Reporting Significant Deficiency

Response: The YMCA of Metropolitan Fort Worth has strengthened its review process to ensure all required federal grant reports are submitted by the established deadlines. Reports will be prepared and reviewed at least one week prior to the required submission date. A compliance calendar will be main...

Response: The YMCA of Metropolitan Fort Worth has strengthened its review process to ensure all required federal grant reports are submitted by the established deadlines. Reports will be prepared and reviewed at least one week prior to the required submission date. A compliance calendar will be maintained and monitored by the Finance Department. All reports will undergo supervisory review by a staff member other than the preparer before submission. Date of Completion: September 30, 2025 Person Responsible to Ensure Completion: Kristen Lee, Chief Finance & Administration Officer

View Audit 370064

Corrective Action Plans

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