Corrective Action Plans

Finding 1206353 (2023-004)

Material Weakness 2023

HOUSING AUTHORITY OF THE CITY OF MILWAUKEE

WI

Special Tests & Provisions Eligibility HUD Housing Programs

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 Special Tests & Provisions

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 Material Weakness Reporting § 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

Material Weakness Reporting Matching / Level of Effort / Earmarking

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

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

Material Weakness Reporting School Nutrition Programs

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

Subrecipient Monitoring Material Weakness Reporting

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 Subrecipient Monitoring Material Weakness § 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

Finding 1176971 (2023-005)

Material Weakness 2023

Papa Ola Lokahi

HI

Allowable Costs / Cost Principles Material Weakness Matching / Level of Effort / Earmarking

Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Fina...

Views of Responsible Officials and Planned Corrective Action The Organization understands the criteria cited re: Title 2, Subtitle A Chapter II, Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), §200.334, requiring “Financial records, supporting documents, statistical records, and all other non-Federal records must be retained for a period of three years from the date of submission of the final expenditure report…”, and recommendation made. However, because two programs are listed U.S. Department of Education and the U.S. Department of Health and Human Services, the Organization will work with the auditors to: A. Better understand the findings (i.e., inconsistent document retention substantiating contractor performance of services) identified by the field work and expenditure and contractor testing, as it relates to which program, and which subrecipient contractor the findings relate to; B. Clarify the specific source and subcontractor awarding and payment criteria as noted in the Organization’s award and sub-award criteria, and subsequently reflected in the subcontractor contract(s); C. Analyze the findings to identify root causes and/or conditions in related contract monitoring processes that resulted in inconsistent document retention practices; and D. Address and implement corrective actions through identified needs (e.g., policy development and implementation, contract monitoring processes and procedures). The Organization will prioritize the above with the auditors as soon as possible, so the appropriate corrective actions can be addressed.

View Audit 390799

Finding 1175541 (2023-007)

Material Weakness 2023

Saint Anthony Health Ministries and Subsidiaries

IL

Subrecipient Monitoring Material Weakness Reporting § 200.334

The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is revie...

The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is reviewed by the vice president of finance.

View Audit 389331

Finding 1175235 (2023-008)

Material Weakness 2023

Oregon Coast Community Action

AL

Matching / Level of Effort / Earmarking Subrecipient Monitoring Eligibility

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract...

Finding 2023-008 – Eligibility – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Low-Income Home Energy Assistance ALN# 93.568 (Repeat 2022-015) US Department of Health and Human Services Passed through Oregon Housing and Community Services Federal Grant/Contract Number: 2302ORLIEA, 2202ORLIEA Grant period – 2022 & 2023 ORCCA is aware of lack of documentation and internal control during the audit period due to various reasons, mainly short staffing and staff turnover and has been working hard to prevent such occurrences. The Finance staff (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) have already started communicating with program directors if any such issues are observed. The Energy program has been current on the required reporting since the referenced audit period. The program is aware of the grants’ requirements now. Additionally, ORCCA plans to utilize grant tracker system with the ability to send reminders for important dates to avoid future delinquent reporting that was experienced during the audit period. The system will be utilized by the program directors as well as finance team (Finance Director, Accounting Manager, Program Fiscal Compliance Coordinator) working with grants/directors. The estimated date of completion of this process is January 31, 2026. ORCCA’s current process at the Energy program level has already improved to ensure proper documentation of eligibility. The Energy program director and staff are implementing this internal control at the program level to review the supporting documents and information and proper coding to the correct period.

View Audit 388923

Finding 1175220 (2023-005)

Material Weakness 2023

Cooperstown Medical Center D/b/a Dakota Regional Medical Center

ND

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

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Acco...

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Finding Summary The Medical Center does not ensure that the required USDA Accounts (General Account, Construction Account, Debt Service Account, and Reserve Account) were reconciled on a timely basis. This increases the possibility that errors related to the USDA Accounts and other accounts impacted by the USDA Accounts, including construction in progress, are not properly stated in the financial statements. In addition, there could be amounts expended from the USDA Accounts that do not meet the requirements and those expenditures would not be identified in a timely manner. Corrective Action Plan Internal controls will be updated to have a formalized process established to ensure timely reconciliation of the USDA Accounts as well as a review process of those reconciliations each month Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO; Jasen Walker, Controller Anticipated Completion Date Complete.

View Audit 388912

Finding 1175219 (2023-004)

Material Weakness 2023

Cooperstown Medical Center D/b/a Dakota Regional Medical Center

ND

Reporting Material Weakness Matching / Level of Effort / Earmarking

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Cli...

Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Clinics Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.301 Program Name COVID 19 Small Rural Hospital Improvement Grants Finding Summary Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date Ongoing

View Audit 388912

Finding 1174702 (2023-013)

Material Weakness 2023

City of Woonsocket

RI

Procurement, Suspension & Debarment Eligibility HUD Housing Programs

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The depar...

Reference Number: 2023-013 Finding: Eligibility Determinations for the HOME Program Name of Contact Person: Lara Auclair Corrective Active Plan: The City of Woonsocket has developed policies and procedures in order to facilitate the proper standards for documentation of income eligibility. The department will ensure that proper approvals will be solicited from the HOME Program Compliance Officer after thorough review. Written agreement documentation will be revised to include the requirements from the new compliance manual. The City of Woonsocket plans to procure grant management software which will streamline the application process and allow for improved recordkeeping to ensure compliance with all policies and procedures. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174701 (2023-012)

Material Weakness 2023

City of Woonsocket

RI

Allowable Costs / Cost Principles Reporting Special Tests & Provisions

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...

Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174698 (2023-010)

Material Weakness 2023

City of Woonsocket

RI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.328 § 200.329

Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAP...

Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAPER. The staff worked diligently to find all required data for the report and participated in training courses to prepare for future CAPERs. Proposed Completion Date: 3/31/26

View Audit 388245

Finding 1174694 (2023-008)

Material Weakness 2023

City of Woonsocket

RI

Material Weakness Reporting Internal Control / Segregation of Duties § 200.328 § 200.329

Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evalu...

Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evaluation reports in compliance with program requirements. Designated staff will be responsible for tracking reporting deadlines, ensuring timely submissions, and maintaining thorough documentation of all reports. Management will conduct regular reviews to monitor compliance and address any deficiencies promptly. Proposed Completion Date: 6/30/26

View Audit 388245

Finding 1174193 (2023-001)

Material Weakness 2023

Gbapp, Inc.

CT

Material Weakness Reporting Internal Control / Segregation of Duties

Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustme...

Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustments, subsequent to year end, were required to conform the financial statements and schedules to professional standards in all material respects. Accordingly, the Federal Data Collection Form and the Connecticut EARS filings were not submitted timely. Statement of Concurrence or Nonconcurrence: GBAPP, Inc. concurs with this audit finding. Corrective Action: Management has since retained additional personnel to assist in performing these duties and is in the process of implementing additional policies and procedures. GBAPP supplemented its accounting personnel with an external CPA with extensive experience in accounting and reporting for non-profit organizations that receive federal and state funding, and who also possesses the suitable skills, knowledge and experience in financial, government and grants management reporting to ensure that this finding will not be repeated. Name of Contact Person: Nancy Kingwood President/Executive Director 203-366-8255 nkingwood@gbapp.org Projected Completion Date: Immediately

View Audit 387906

Corrective Action Plans

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