Corrective Action Plans

Finding 570678 (2024-003)

Material Weakness 2024

KY

Questioned Costs Reporting Matching / Level of Effort / Earmarking § 200.303

We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleas...

We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleased to have made progress on this front, but also extremely appreciative for the guidance and feedback from those reporting agencies. KYEM and FEMA document tracking and reporting is now handled entirely inhouse. Members of the Cumberland County Management Team have responded timely and in full to requests for information and we will continue to do so. The lack of certain systems and processes from years past is no longer a concern of the current administration. It is true that work is still needed to organize and understand some of the work from the last several years, but the Management Team believes that the new process will eliminate most of if not all confusion moving forward on any future disasters.

View Audit 361704

Finding 570673 (2024-001)

Significant Deficiency 2024

Maple City Health Care Center, Inc.

IN

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

Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") ...

Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") system. Recommendation: The Organization should review internal controls over updates to its sliding fee scale each year to ensure it is properly updated. Corrective Action Plan: The organization has updated fees in the electronic medical record and made sure that those match approved nominal fees and will make sure they are in alignment going forward. Contact Person Responsible: Assistant Director of Finance Expected Completion date: June 30, 2025

View Audit 361694

Finding 570663 (2024-004)

Material Weakness 2024

Tuerk House, Inc.

MD

Questioned Costs Reporting Internal Control / Segregation of Duties

Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has in...

Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has initiated corrective actions to improve internal controls over financial and programmatic reporting. These actions include: ·Establishing a standardized reconciliation process to ensure that all amounts reported in financial reports are tied directly to supporting documentation from the general ledger and other internal financial systems. ·Implementing a dual-review protocol requiring reports to be reviewed and approved by both finance and program staff before submission to funding agencies. · Providing targeted training to relevant personnel on grant reporting requirements, with an emphasis on reporting accuracy, documentation standards, and deadlines. ·Coordinating regular meetings between finance and program departments to align data and ensure consistency between financial and programmatic reporting (e.g., patient counts, service metrics, etc.). ·Developing a reporting calendar to track all reporting requirements and facilitate timely and accurate submissions. We are committed to ensuring accurate and compliant reporting going forward and will monitor implementation closely to prevent recurrence. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025

View Audit 361681

Finding 570660 (2024-002)

Material Weakness 2024

Tuerk House, Inc.

MD

Allowable Costs / Cost Principles Questioned Costs Period of Performance § 200.308 § 200.309 § 200.334 § 200.403

Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditu...

Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs. To address this finding, Tuerk House is taking the following corrective actions: ·Implementing a formal time and effort certification process that requires employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. ·Developing a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. ·Requiring that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. ·Establishing a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff will be conducted to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025

View Audit 361681 Questioned Costs: $1

Finding 570615 (2024-001)

Material Weakness 2024

Scott County Redevelopment and Housing Authority

VA

Questioned Costs HUD Housing Programs Cash Management

Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are n...

Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are not receiving enough funding to cover the expenses for our program. Currently, we are working with our Field Representative, Wilma Henry and Finance Management, Lin Wang to release our reserves to resolve this issue.

View Audit 361639 Questioned Costs: $1

Finding 570613 (2024-001)

Significant Deficiency 2024

City of Grand Forks

ND

Subrecipient Monitoring Questioned Costs Reporting

Contact Person – Candice Stjern – Assistant Finance Director Planned Corrective Action – The City will review and update its internal controls regarding reporting to ensure all reports are filed on a timely basis. Planned Completion Date - Immediately

View Audit 361633

Finding 570587 (2024-001)

Material Weakness 2024

Niles City School District

OH

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

The treasurer will review the monthly invoices and will initial the invoices

View Audit 361623 Questioned Costs: $1

Finding 570581 (2024-004)

Significant Deficiency 2024

Boys & Girls Clubs of Northeast Ohio

OH

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

BGCNEO corrected the overbilling in June and July before the grant period closed. BGCNEO will have stronger controls around the grant period year ends to ensure double billings are less likely to occur.

View Audit 361612 Questioned Costs: $1

Finding 570580 (2024-003)

Significant Deficiency 2024

Boys & Girls Clubs of Northeast Ohio

OH

Internal Control / Segregation of Duties Questioned Costs

BGCNEO will utilize controls within the payroll system to increase employee responsibility and place more emphasis on supervisor review responsibilities. Supervisors will be offered additional training by the administration staff during the year.

View Audit 361612

Finding 570575 (2024-001)

Significant Deficiency 2024

Rocking Horse Children's Health Center Dba Rocking Horse Center

OH

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.430

Corrective Action Plan June 26, 2025 U.S. Department of Health and Human Services Health Resources and Services Administration Rocking Horse Community Health Center and Affiliate respectively submits the following corrective action plan for the year ended December 31, 2024. Clark, Schaefer, Hac...

Corrective Action Plan June 26, 2025 U.S. Department of Health and Human Services Health Resources and Services Administration Rocking Horse Community Health Center and Affiliate respectively submits the following corrective action plan for the year ended December 31, 2024. Clark, Schaefer, Hackett & Co. 14 East Main Street, Suite 500 Springfield, OH 45502 Audit period: January 1, 2024 – December 31, 2024 The findings from the June 26, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS Department of Health and Human Services 2024-001 Health Center Cluster Program – ALN # 93.527; Grant No. H2E Significant Deficiency: See Finding 2024-001 Recommendation: Management should strengthen its internal controls over payroll charges to federal awards by ensuring consistent adherence to its time and effort certification policies as well as conduct periodic reviews of payroll documentation to verify compliance with established policies and federal requirements. Action Taken: We concur with the recommendation and will implement formal policies and procedures around obtaining time and effort certifications by June 30, 2025.

View Audit 361604 Questioned Costs: $1

Finding 570574 (2024-003)

Significant Deficiency 2024

YWCA Madison, Inc.

WI

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.436

YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – December 31, 2024 The findi...

YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – 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 numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS SIGNIFICANT DEFICIENCY 2024-001 Recommendation: Management should implement procedures to ensure continuity of key financial controls during periods of personnel transition. This includes assigning interim reviewers, establishing clear handover protocols, and enforcing timely documentation of reviews to maintain financial oversight. Action Taken: Under the leadership of our new fractional CFO and outsourced accounting firm, we have implemented an accounting close and financial reporting management system using ClickUp. Each task impacting key financial controls now has both a designated preparer and reviewer. The system automatically tracks and displays the completion status of each control. Further review of financial schedules is documented through Google Drive approvals. Transitioning from manual to system-driven documentation ensures that, during staffing changes, task reassignments are more visible to all responsible team members. It is important to note that, due to capacity constraints during the transition, immediate reassignment of responsibilities was not feasible. However, once new team members were onboarded, a cumulative review of the period was conducted to ensure the completeness and accuracy of the financial information—ultimately reflected in an unmodified financial audit opinion. MATERIAL WEAKNESS 2024-002 Recommendation: Assign clear responsibility for maintaining and reviewing the monitoring checklist. Management should establish a recurring schedule (e.g., monthly or quarterly) for checklist reviews and ensure the results are documented and retained for accountability and audit purposes. Action Taken: The new fractional CFO, Grants & Compliance Director, and CEO have revised the monitoring checklist to separate financial and compliance controls, as these operate on different schedules. Financial controls have been integrated into the financial management project system in ClickUp. Compliance controls will be maintained within the grant management system and embedded into the grant management and reporting processes. FEDERAL AWARD FINDINGS DEPARTMENT OF TRANSPORTATION STATE OF WISCONSIN DEPARTMENT OF TRANSPORTATION 2024-003 Formula Grants for Rural Areas and Tribal Transit Program — Assistance Listing No. 20.509 Recommendation: Management should conduct a review of depreciation charges for the current and future years to ensure that federally funded assets are excluded from depreciation allocations to federal programs. Action Taken: We have added a new depreciation expense account to distinguish between allowable and non-allowable depreciation expenses in grant expenditure allocations. If there are questions regarding this plan, please call Tania Ibarra, CPA, at 608.347.6747. Sincerely, Geraldine Paredes Vásquez CEO gpvasquez@ywcamadison.org

View Audit 361592 Questioned Costs: $1

Finding 570555 (2024-002)

None 2024

Barrier Free Living Holding, Inc.

NY

Questioned Costs Eligibility

Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Dire...

Management will continue to accumulate proper supporting documentation to support the organization’s compliance with the eligibility compliance requirement and to provide such documentation, when legally possible. Responsible parties: Cynthia Amodeo, Chief Executive Officer Myra Ricard, Program Director Anticipated Completion Date: Not Applicable as this is not correctable at this time due to New York State Executive Order 19-ADM-05; 19-OCFS-ADM-03.

View Audit 361575

Finding 570554 (2024-005)

None 2024

City of Shepherdsville

KY

Questioned Costs Reporting Internal Control / Segregation of Duties

The City has retained a consultant to clean up old data, and we are commi􀆩ed to closing the books by August 31, 2025. As a result of improving our processes and 􀆟ghtening internal controls, we can begin our audit process much sooner than in prior years and have all aspects of the audit completed 􀆟me...

The City has retained a consultant to clean up old data, and we are commi􀆩ed to closing the books by August 31, 2025. As a result of improving our processes and 􀆟ghtening internal controls, we can begin our audit process much sooner than in prior years and have all aspects of the audit completed 􀆟mely. This will be overseen by the Finance Director.

View Audit 361571

Finding 570550 (2024-001)

Significant Deficiency 2024

Austin Street Center

TX

Questioned Costs Procurement, Suspension & Debarment § 200.320

Year Ended: October 31, 2024 Finding Number: 2024-001 Name oflndividual Responsible for Correction Action: Alissa Rodgers, CFO Cause: Austin Street was previously in compliance due to using a Sole Source Provider for Food that provided the food services as well as the food supply vendors. August Str...

Year Ended: October 31, 2024 Finding Number: 2024-001 Name oflndividual Responsible for Correction Action: Alissa Rodgers, CFO Cause: Austin Street was previously in compliance due to using a Sole Source Provider for Food that provided the food services as well as the food supply vendors. August Street discontinued services with the food service provider however maintained the food supply vendors. Since they were not new vendors it was misunderstood to pass those vendors through procurement once again since the sole source was no longer connected to the food program. Corrective Action Plan: On April 17, 2025, Austin Street Center's business office has published and distributed an RFP for food vendors to comply with procurement requirements as food costs are usually more than $250,000 per year. ProcW"ement Processes have been followed in all other areas of the organization and Austin Street is placing month end procedures in place to ensure no vendors unexpectedly rise above thresholds that require additional procurement or analysis.

View Audit 361562 Questioned Costs: $1

Finding 570515 (2024-001)

Significant Deficiency 2024

Promise Healthcare Nfp

IL

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

Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disa...

Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create list of grants with pertinent contract terms for monitoring and reference. Highlight grants with term end dates within the fiscal year. 2. Update Grant Tracking workpapers to alert on grant year end and create allocation tab to separate payroll expenses that crossover grant end terms. Review non-payroll expenses to ensure they belong to proper grant term. 3. Monitor progress and review grants at fiscal year end to ensure process was followed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: 8/31/2025

View Audit 361495 Questioned Costs: $1

Finding 570490 (2024-004)

Material Weakness 2024

Akron-Canton Regional Airport Authority

OH

Questioned Costs Subrecipient Monitoring Material Weakness § 200.326

2024-004 The Akron – Canton Regional Airport Authority request wage reports with all projects. The majority of these reports are submitted with pay applications. The standard practice is that the company overseeing the construction management of the projects submits these reports to the Airport. The...

2024-004 The Akron – Canton Regional Airport Authority request wage reports with all projects. The majority of these reports are submitted with pay applications. The standard practice is that the company overseeing the construction management of the projects submits these reports to the Airport. The Airport had a couple projects without a firm overseeing the construction management. There were a few pay applications associated with these projects that the Airport did not receive wage reports and had to request after the fact. The Airport has since involved more staff members to review pay application for required information. Completed June of 2025 James Krum, VP of Finance and Administration

View Audit 361449

Finding 570486 (2024-001)

Material Weakness 2024

Community Coalition Against Human Trafficking

TN

Questioned Costs Subrecipient Monitoring Cash Management § 200.403 § 200.430

Management concurs with the recommendation to implement internal controls to ensure all costs charged to the program are accurate, allowable, and properly allocated in accordance with the terms of the federal award, and that there is proper review and approval.

View Audit 361435 Questioned Costs: $1

Finding 570471 (2024-001)

Material Weakness 2024

Institute for Applied Ecology

OR

Reporting Questioned Costs Material Weakness

The Institute provided a corrected report for the purposes of the Audit and will identify and implement enhanced procedures and controls to correctly produce and review the SEFA for future submissions. Anticipated Completion Date: June 2025

View Audit 361424

Finding 570470 (2024-003)

Material Weakness 2024

International Registration Plan, Inc.

VA

Reporting Questioned Costs Allowable Costs / Cost Principles § 200.309 § 200.403

Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant managem...

Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant management procedures have been revised to verify that services are received and costs incurred within the authorized period of performance in accordance with 2 CFR § 200.403 before the costs are charged to a federal award. Staff involved in grant management will receive targeted training on 2 CFR requirements related to period-of-performance compliance and allowable cost timing. Anticipated Completion Date: September 30, 2025

View Audit 361417 Questioned Costs: $1

Finding 570077 (2024-028)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions,...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that documentation of all required reports are submitted in a timely manner in accordance with grant terms and conditions, including evidential support of timing of submission of required reports such as submission confirmations or logs. These internal controls ensure oversight of reporting requirements that are outsourced to vendors.

View Audit 361368

Finding 570075 (2024-027)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles § 200.403 § 200.405

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Unif...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Uniform Guidance.

View Audit 361368 Questioned Costs: $1

Finding 570074 (2024-026)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.403

agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to subm...

agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to submitting reimbursement requests.

View Audit 361368 Questioned Costs: $1

Finding 570072 (2024-025)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.403

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance wi...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance with regard to the period of performance requirements.

View Audit 361368 Questioned Costs: $1

Finding 570070 (2024-024)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including r...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including review and monitoring of process and procedures. In addition, documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such expenses, will be retained in accordance with federal regulations.

View Audit 361368 Questioned Costs: $1

Finding 570066 (2024-023)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles § 200.305

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, sta...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, state, and similar types of grants and contracts.

View Audit 361368

Corrective Action Plans

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