Corrective Action Plans

Finding 1163379 (2024-006)

Material Weakness 2024

Economic Development Bank for Puerto Rico

PR

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs

Management notes that all contracts and amendments are executed in accordance with Recipient systems and procedures. Observations are acknowledged as an opportunity to improve the tracking and notification processes to the PRDOH Legal Division.

View Audit 372904

Finding 1163365 (2024-001)

Material Weakness 2024

Biostl

MO

Questioned Costs Subrecipient Monitoring

The audit identified that a subrecipient submitted an expense reimbursement request exceeding the incurred grant expenses through the submission date. This issue resulted from a misinterpretation by the subrecipient team regarding the correct procedures for completing the expense recording worksheet...

The audit identified that a subrecipient submitted an expense reimbursement request exceeding the incurred grant expenses through the submission date. This issue resulted from a misinterpretation by the subrecipient team regarding the correct procedures for completing the expense recording worksheet. Priorto FY 2025, existing controls over subrecipient monitoring were not effectively designed to detect this error. In 2025, BioSTL Grant Management and Finance leadership implemented a comprehensive post-award grant process, including extensive policies and procedures for subrecipient management and monitoring. Additionally, early in 2025, internal policies concerning subrecipient invoicing procedures were enhanced to require additional documentation and review for all subrecipient submissions of grant funds. These improvements have proven effective in identifying and rectifying errors prior to submission. To support these initiatives, BioSTL has conducted training sessions, reviewed implementation procedures, and held regular meetings to ensure that all BioSTL personnel and subrecipient staff fully understand the requirements and have ample opportunities for communication regarding grant draws. Furthermore, to align BioSTL Policies and Procedures, a comprehensive handbook has been developed for all virtual and on-site monitoring activities. These revised procedures mandate at least one virtual monitoring session every six months and at least one on-site monitoring session per participant throughout the grant period, with additional monitoring based on risk assessment outcomes. This schedule more closely aligns with CFR requirements and ensures oversight activities are conducted thoroughly and without lapses. On-site monitoring will be completed for all subrecipients before the end of the fiscal year, which closes on December 31, 2025.

View Audit 372878 Questioned Costs: $1

Finding 1163357 (2024-006)

Material Weakness 2024

Pembina County Water Resource District

ND

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

2024-006 – WATERSHED REHABILITATION PROGRAM – LACK OF CONTROLS AND IMPROPER PERIOD OF PERFORMANCE – WRD – ALN 10.916 – MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition Pembina County Water Resource District applied costs to the Watershed Rehabilitation Program after the period of performance, wh...

2024-006 – WATERSHED REHABILITATION PROGRAM – LACK OF CONTROLS AND IMPROPER PERIOD OF PERFORMANCE – WRD – ALN 10.916 – MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition Pembina County Water Resource District applied costs to the Watershed Rehabilitation Program after the period of performance, which shows a lack of internal controls. The total value of the expenses past the period of performance end date was approximately $170,468 which occurred through September 14, 2024, more than a month past the period of performance end date. Corrective Action Plan: We agree we will ensure costs are in the proper period of performance going forward Anticipated Completion Date: FY2025

View Audit 372866 Questioned Costs: $1

Finding 1163322 (2024-001)

Material Weakness 2024

Koinonia, Inc. 053-11202

NC

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties § 200.302 § 200.303

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN October 31, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the...

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN October 31, 2025 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The finding from the year ended December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - Financial Statement Audit and Federal Award Program Audit Finding 2024-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2024-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting and financial procedures, system of internal controls and policies. If HUD has questions regarding this corrective action plan, please call 828-758-2617. Sincerely yours, Chassidy Triplett Project Administrator Koinonia, Inc.

View Audit 372842 Questioned Costs: $1

Finding 1163308 (2024-002)

Material Weakness 2024

Heading Home

NM

Questioned Costs Allowable Costs / Cost Principles Reporting

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their ro...

Heading Home management is in agreement with this finding. After years of turnover in key management positions steps have been taken to address staffing challenges and these positions have been successfully staffed with high-quality individuals who bring extensive knowledge and expertise to their roles. These positions include a new Chief Executive Officer, Director of Operations, Chief Financial Officer, and Director of Human Services. To address challenges in accounting and finance Heading Home had contracted with a local CPA firm specializing in nonprofit accounting and financial reporting to assist the CFO with daily accounting tasks, the monthly close, financial reporting to management and the board of directors, and to facilitate and ensure audits are completed timely each year. The new management group is committed to maintaining a skilled and competent team in key financial roles. Due to the backlog of billings at the opening of FY23, the billing submissions and quarterly reports for the first quarter were submitted late. With the new staff and assistance, these billings and quarterly reports were brought current as quickly as possible. They are now current and being submitted in a timely manner. Management’s corrective action plan was fully implemented by June 30, 2025, and anticipate that there will be no further issues. Personnel responsible for ensuring implementation include Connie Chavez, Executive Director, and Debbie Brickman, Chief Financial Officer.

View Audit 372829

Finding 1163275 (2024-002)

Material Weakness 2024

Youthcare

WA

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective Action Plan For the Year Ended December 31, 2024 Contact Person(s): De Angelo Jones, Finance Director Deangelo.jones@youthcare.org Finding 2024-002 Significant deficiency in internal controls over compliance related to reporting. Explanation and specific reasons for disagreement with the ...

Corrective Action Plan For the Year Ended December 31, 2024 Contact Person(s): De Angelo Jones, Finance Director Deangelo.jones@youthcare.org Finding 2024-002 Significant deficiency in internal controls over compliance related to reporting. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement. Corrective action planned:  Develop a contract expenditure compliance review process created with final review and approval by Finance Director. Anticipated completion date: Fixed January 1, 2025

View Audit 372803

Finding 1163270 (2024-002)

Material Weakness 2024

Wingo Elderly Housing Corporation D/b/a Locust Ridge Apartments

KY

Questioned Costs

Management will make sure the audited financial statements are filed into the REAC system 90 days after the fiscal year-end in future years.

View Audit 372786 Questioned Costs: $1

Finding 1163269 (2024-001)

Material Weakness 2024

Wingo Elderly Housing Corporation D/b/a Locust Ridge Apartments

KY

Questioned Costs Cash Management HUD Housing Programs

Management will deposit required amounts.

View Audit 372786 Questioned Costs: $1

Finding 1163241 (2024-002)

Material Weakness 2024

East Valley Community Health Center, Inc.

CA

Questioned Costs Special Tests & Provisions

Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. Planned Corrective Actions: To strengthen compliance with ou...

Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. Planned Corrective Actions: To strengthen compliance with our sliding fee discount policy, East Valley Community Health Center has implemented several corrective measures. Re-training for intake and billing staff began in April 2025 and is ongoing as part of our quarterly training cycle, In addition, we are currently reviewing our sliding fee discount policy and procedures to ensure they are clear, consistently applied, and aligned with HRSA guidance and the Health Center Program Compliance Manual. Monthly audits of patient encounters involving sliding fee adjustments began in October 2024 by the billing department and are now a permanent component of our internal compliance process. Audit results are reviewed by the Revenue Cycle Manager and shared with Clinic Managers, Front Office Leads, and Senior Leadership to ensure accountability and prompt corrective action when needed. The CFO is responsible for overseeing these processes and ensuring that all compliance measures are implemented effectively.

View Audit 372749

Finding 1163234 (2024-002)

Material Weakness 2024

Benton Franklin Community Action Committee

WA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

BFCAC made a change in personnel during 2024. Subsequently, BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for thi...

BFCAC made a change in personnel during 2024. Subsequently, BFCAC has emphasized the need to maintain supporting documentation for all charges, including changes to timesheets, and supporting documentation for manual adjustments. The Executive Director and the Finance Manager are responsible for this corrective action.

View Audit 372721 Questioned Costs: $1

Finding 1163220 (2024-005)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Questioned Costs Reporting § 200.329

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create and or update policies and procedures to ensure all required reports are submitted timely and accurately. Explanation of disagre...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create and or update policies and procedures to ensure all required reports are submitted timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has developed and is in the process of implementing a tracking system for compliance deadlines, including report submissions. Name of the contact person responsible for corrective action: Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163219 (2024-004)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Questioned Costs

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create proper policies and procedures to ensure indirect costs are properly calculated and tracked. Explanation of disagreement with au...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend the organization create proper policies and procedures to ensure indirect costs are properly calculated and tracked. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: GHN has developed a procedure as well as hired additional staff to correctly track, calculate, and review indirect costs. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163218 (2024-003)

Material Weakness 2024

Greater Columbia Accountable Community of Health

WA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreemen...

The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization’s procurement policy is followed and that procurement procedures are documented, reviewed and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We are reviewing our current policies and procedures in these areas to determine if any changes should be implemented. Greater Health Now has increased trainings for staff members in terms of the documentation required to purchase goods and services with grant funds. Furthermore, to strengthen our oversight of sole-source contracts awarded with program and non-program funds, we will introduce stringent measures requiring thorough documentation of the vendor’s or contractor’s qualifications. Names of the contact persons responsible for corrective action: Jan Warren, Director of Finance & Amber Henderson, Chief Organization Excellence & Strategy Officer Planned completion date for corrective action plan: December 31, 2025

View Audit 372710

Finding 1163192 (2024-001)

Material Weakness 2024

City of Clarksville Gas & Water

TN

Questioned Costs Subrecipient Monitoring Reporting § 200.502 § 200.510

Management concurs with the finding. Procedures have been implemented to enhance year-end review of grant activity, including reconciliation of grant expenditures and receivables to the SEFA and general ledger prior to issuance. The Departments’ will continue to monitor these processes to ensure com...

Management concurs with the finding. Procedures have been implemented to enhance year-end review of grant activity, including reconciliation of grant expenditures and receivables to the SEFA and general ledger prior to issuance. The Departments’ will continue to monitor these processes to ensure compliance with the Uniform Guidance reporting requirements. Anticipated Completion Date: October 31, 2025

View Audit 372690

Finding 1163070 (2024-006)

Material Weakness 2024

Productive Alternatives, Inc.

MN

Internal Control / Segregation of Duties Questioned Costs Cash Management § 200.303

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdown prior to submission. Explanation of disagreement with audit findin...

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: A separate individual with supervisory authority over the preparer should be assigned to review and approve the cash drawdown prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure there are proper segregation of duties regarding the cash drawdown process. Name(s) of the contact person(s) responsible for corrective action: Carrie Beithon, Director of Financial Services Planned completion date for corrective action plan: 12/31/2026

View Audit 372641

Finding 1163067 (2024-003)

Material Weakness 2024

Productive Alternatives, Inc.

MN

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

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The Organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should rec...

Formula Grants for Rural Area and Tribal Transit Program Federal Assistance Listing #20.509 Recommendation: The Organization should ensure proper documentation is retained to support the approval of allowable costs by someone knowledgeable of the grant and its guidelines. The Organization should reconcile the budgeted payroll and benefits allocations charged to the grant after-the-fact to actual work performed to ensure the allocation was accurately reflected. The Organization should ensure expenditures are charged to proper grant year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will ensure moving forward that proper support is retained for allowable costs charged to the grant and budgeted amounts are reconciled to after-the fact actual amounts. Name(s) of the contact person(s) responsible for corrective action: Carrie Beithon, Director of Financial Services Planned completion date for corrective action plan: 12/31/2026

View Audit 372641 Questioned Costs: $1

Finding 1163060 (2024-001)

Material Weakness 2024

Town of York

ME

Procurement, Suspension & Debarment Questioned Costs Subrecipient Monitoring

Management’s response/corrective action plan: YSD acknowledges the deficiency and attributes it to a lack of knowledge on the part of the Special Education group for this requirement. The appropriate personnel have been notified and have been provided sufficient training materials to address this is...

Management’s response/corrective action plan: YSD acknowledges the deficiency and attributes it to a lack of knowledge on the part of the Special Education group for this requirement. The appropriate personnel have been notified and have been provided sufficient training materials to address this issue. It is, however, possible that since this finding covers only the FY24 fiscal year, that additional violations have occurred in the FY25 fiscal year.

View Audit 372626

Finding 1163053 (2024-002)

Material Weakness 2024

Eastern Market Corporation

MI

Questioned Costs Procurement, Suspension & Debarment Reporting

Condition: Eastern Market's reporting package was not completed and submitted to the Federal Audit Clearinghouse within nine months after year-end. Corrective Action Plan: Corrective Action Planned: Management acknowledges the finding and agrees with the recommendation. Many of the causes identified...

Condition: Eastern Market's reporting package was not completed and submitted to the Federal Audit Clearinghouse within nine months after year-end. Corrective Action Plan: Corrective Action Planned: Management acknowledges the finding and agrees with the recommendation. Many of the causes identified were unique to this current reporting period and will either not be present in the next reporting period or will enhance the reporting capabilities of Eastern Market to eliminate the risk going forward. Further, this was the first single audit for the staff and accounting department at Eastern Market which increased the risk of non-compliance. The staff now has this familiarity to ensure timely submission going forward. Name(s) of Contact Person(s) Responsible for Corrective Action: Tyler Walz, Director of Accounting, Quatrro Business Support Services; Katy Trudeau, President and CEO, Eastern Market Corporation Anticipated Completion Date: Corrective action plan implemented as of September 2025.

View Audit 372621

Finding 1163000 (2024-007)

Material Weakness 2024

New Brighton Borough

PA

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

Recommendation: We recommend that the Borough strengthen its internal controls over the authorization of ARPA-funded expenditures by ensuring that all individual disbursements are reviewed and approved by the Borough Council or other designated officials prior to payment. Alternatively, if the Borou...

Recommendation: We recommend that the Borough strengthen its internal controls over the authorization of ARPA-funded expenditures by ensuring that all individual disbursements are reviewed and approved by the Borough Council or other designated officials prior to payment. Alternatively, if the Borough intends to continue approving projects on an overall basis, it should establish and document clear procedures specifying when and how individual payments within approved projects are deemed authorized. Management's Response: Management agrees that additional clarification and documentation of the approval process for ARPA-funded disbursements will strengthen internal controls and ensure transparency in the use of Federal funds. The Borough will review its current approval procedures and implement guidance specifying how individual disbursements under previously approved ARP A projects are to be authorized and documented. Where appropriate, individual payments will be presented to the Borough Council for approval prior to processing.

View Audit 372591

Finding 1162977 (2024-004)

Material Weakness 2024

Valle Verde Housing-Municipality of Adjuntas

PR

Questioned Costs Reporting Significant Deficiency

Management concurs with the Finding. We gave instructions to the Fiscal Staff to maintain a dateline control sheet to ascertain that required reports were submitted within the due date and to retain evidence on file about each submission.

View Audit 372579

Finding 1162976 (2024-003)

Material Weakness 2024

Valle Verde Housing-Municipality of Adjuntas

PR

Questioned Costs Reporting Significant Deficiency

Management concurs with the Finding. The fiscal year 2023-2024 Single Audit reporting package will be immediately uploaded to the Federal Audit Clearinghouse (FAC) web portal upon receipt of the auditor’s reports. As a preventive actions for fiscal year, 2024–2025, the Municipality’s financial staff...

Management concurs with the Finding. The fiscal year 2023-2024 Single Audit reporting package will be immediately uploaded to the Federal Audit Clearinghouse (FAC) web portal upon receipt of the auditor’s reports. As a preventive actions for fiscal year, 2024–2025, the Municipality’s financial staff, with the support of a financial consulting firm, have been working to prepare the FY 2024-2025 financial statements and Single Audit deliverables to comply with the established deadline.

View Audit 372579

Finding 1162970 (2024-003)

Material Weakness 2024

City of Saratoga Springs, New York

NY

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.412 § 200.512

The City has established policies and procedures related to grant administration and accounting guidelines for allowable costs. The City is aware of the deadline for the submission of the Single Audit. The City is taking steps to ensure that personnel have received guidance and training regarding gr...

The City has established policies and procedures related to grant administration and accounting guidelines for allowable costs. The City is aware of the deadline for the submission of the Single Audit. The City is taking steps to ensure that personnel have received guidance and training regarding grant accounting, including deadlines for the audit. Responsible Party and Anticipated Completion Date: Commissioner of Finance Minita Sanghvi 12/31/2026

View Audit 372565

Finding 1162968 (2024-004)

Material Weakness 2024

Menominee County, Wisconsin

WI

Questioned Costs Material Weakness Reporting

Recommendation: CLA recommended that there is an appropriate reviewer of Performance and Expenditure Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County will have someone other than the prepa...

Recommendation: CLA recommended that there is an appropriate reviewer of Performance and Expenditure Report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County will have someone other than the preparer review the report prior to submission going forward. Name(s) of the contact person(s) responsible for corrective action: Kourtney Erickson Planned completion date for corrective action plan: December 31, 2025

View Audit 372563

Finding 1162916 (2024-009)

Material Weakness 2024

City of Peabody

MA

Questioned Costs Material Weakness Reporting

Views of Responsible Officials and Planned Corrective Actions: The School District will implement internal control procedures to ensure that the required reporting is completed, retained and maintained in an organized manner. Management plans to implement these procedures in 2026.

View Audit 372554

Finding 1162906 (2024-008)

Material Weakness 2024

City of Peabody

MA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring

Views of Responsible Officials and Planned Corrective Actions: The School District will immediately begin reissuing and recollecting the forms for the education stabilization grant for 2026, as well as into future periods.

View Audit 372554 Questioned Costs: $1

Corrective Action Plans

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