Corrective Action Plans

Finding 570062 (2024-022)

Significant Deficiency 2024

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.302 § 200.329

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to sp...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to design and implement internal controls related to federal program grant management, including assignment of responsibility for grant oversight to specific individuals or departments.

View Audit 361368

Finding 570058 (2024-020)

Significant Deficiency 2024

West Central Mental Health Center, Inc.

CO

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.334

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently ...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently reviewed, approved, submitted, retained and retrievable for the required retention period. This includes quarterly reports, expense reimbursement packets submitted to the grantors, project expenditure reports, or other grant-related records necessary to demonstrate compliance with federal reporting and record retention standards under the federal programs.

View Audit 361368

Finding 570053 (2024-016)

Material Weakness 2024

West Central Mental Health Center, Inc.

CO

Allowable Costs / Cost Principles Questioned Costs Cash Management § 200.430

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Gro...

Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Group will reconcile budgeted and actual fringe benefit costs regularly to ensure continued compliance.

View Audit 361368 Questioned Costs: $1

Finding 570052 (2024-015)

Material Weakness 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 accounting of payroll costs incurred under the federal programs, including re...

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 accounting of payroll costs incurred under the federal programs, including review and monitoring of processes and procedures. Documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such charges, will be retained in accordance with federal regulations.

View Audit 361368 Questioned Costs: $1

Finding 570038 (2024-006)

Significant Deficiency 2024

Passage Home

NC

Questioned Costs Allowable Costs / Cost Principles Cash Management

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Within 60 days of audit issuance, the Interim CFO will conduct training for finance staff regarding accounts payable invoices and sales tax requirements and coding. Updated accounts payable policies and procedures include a process to ensure that the CFO reviews and codes sales tax when checks are prepared, approved and signed. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 09/30/2025

View Audit 361326 Questioned Costs: $1

Finding 570037 (2024-005)

Material Weakness 2024

Passage Home

NC

Allowable Costs / Cost Principles Questioned Costs § 200.302 § 200.403

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as peri...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as periodic internal audits to ensure compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All purchase-related supporting documentation will be transitioned to paper files to eliminate confusion created by the electronic record-keeping system, and to ensure that all staff requiring access to such documentation can immediately and easily retrieve them. Records will be maintained in the Finance Department office for seven years. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025

View Audit 361326 Questioned Costs: $1

Finding 570036 (2024-004)

Material Weakness 2024

Passage Home

NC

Allowable Costs / Cost Principles Questioned Costs § 200.403

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll c...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll costs charged to the grant are adequately supported by detailed payroll records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A payroll salary reconciliation report will be completed after each payroll issued and will be verified against the grant reports, accounting system class coding and employee-specific payroll file(s). Printed reports will be maintained on file in the Finance Department for historical reference. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025

View Audit 361326 Questioned Costs: $1

Finding 570035 (2024-003)

Material Weakness 2024

Passage Home

NC

Questioned Costs Eligibility Material Weakness

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the pr...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing intake forms, provide training to staff on the importance of maintaining proper documentation and the procedures for completing and reviewing eligibility determinations, and implement periodic internal audits to ensure compliance with documentation requirements and to identify any areas needing improvement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Passage Home implemented new programmatic policies and procedures ensuring that a Program Manager or the Program Director reviews and approves (by signature) all new client enrollments prior to case manager assignment. The Program Director will conduct related training for all program staff and will administer quarterly client record audits (peer or supervisor review) to verify ongoing compliance. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 03/26/2025

View Audit 361326

Finding 570034 (2024-002)

Material Weakness 2024

Passage Home

NC

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing forms, provide training to staff on the importance of maintaining proper documentation and the procedure...

Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation establish and enforce a standardized process for completing and reviewing forms, provide training to staff on the importance of maintaining proper documentation and the procedures for completing and reviewing compliance requirements, and implement periodic internal audits to ensure compliance with documentation requirements and to identify any areas needing improvement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During 2024, Passage Home experienced unprecedented change, including extensive staff turnover and extended vacancies in key positions. Of note, the entire leadership team transitioned out, the Supportive Services for Veteran Families Program Manager (SSVF) left, and 4 new SSVF program team members were onboarded within the year. Additionally, the finance department migrated to a new accounting system that ultimately proved to be unsatisfactory for the organization's needs. Management appreciates and agrees with the auditors' recommendations and has implemented and/or initiated the indicated operational adjustments. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 03/26/2025

View Audit 361326

Finding 569989 (2024-001)

Material Weakness 2024

Van Buren Community Mental Health Authority

MI

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

SINGLE AUDIT FOR THE YEAR ENDED SEPTEMBER 30, 2024 CORRECTIVE ACTION PLAN FEDERAL AWARD FINDINGS - Fiscal Year 2024 Finding Number: 2024-001 Procurement Assistance Listing Number: 93.696 Assistance Listing Title: Certified Community Behavioral Health Clinics N ame of Federal Agency: Substance Abuse...

SINGLE AUDIT FOR THE YEAR ENDED SEPTEMBER 30, 2024 CORRECTIVE ACTION PLAN FEDERAL AWARD FINDINGS - Fiscal Year 2024 Finding Number: 2024-001 Procurement Assistance Listing Number: 93.696 Assistance Listing Title: Certified Community Behavioral Health Clinics N ame of Federal Agency: Substance Abuse and Mental Health Services Administration Federal Award Identification Number: H79SM089299 Fiscal Year of Initial Finding: 2024 • Name of the contact person: Tina Boyer, CFO • Corrective Action Plan: Management agrees with this recommendation. VBCMH management will review and update policies and procedures to ensure that allfederal requirements are followed. Anticipated Completion Date: Fiscal Year 2025

View Audit 361252 Questioned Costs: $1

Finding 569979 (2024-005)

Material Weakness 2024

Dillard University

LA

Student Financial Aid Subrecipient Monitoring Reporting § 200.512

The late audit submission was a result of significant leadership and staffing turnover, unresolved audit support items, and missing reconciliations from prior months. The University engaged an external firm to stabilize the finance function and has since appointed an interim Controller. Beginning wi...

The late audit submission was a result of significant leadership and staffing turnover, unresolved audit support items, and missing reconciliations from prior months. The University engaged an external firm to stabilize the finance function and has since appointed an interim Controller. Beginning with FY26, the University will adopt a rolling monthly close schedule, establish an internal audit prep calendar, and define internal deadlines for deliverables to external auditors. These steps will support timely completion of future audits. Target: Audit submission by March 31, 2026 for FY25.

View Audit 361246

Finding 569977 (2024-003)

Material Weakness 2024

Dillard University

LA

Questioned Costs Student Financial Aid Subrecipient Monitoring

This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The ...

This finding resulted from a loan disbursement exceeding regulatory limits for one student. The issue was corrected before the audit report was finalized. The University will strengthen its review process prior to disbursement by ensuring additional loan eligibility is validated and documented. The Financial Aid Office will receive targeted training on aggregate loan monitoring. Corrective actions will be fully implemented by January 31, 2026.

View Audit 361246 Questioned Costs: $1

Finding 569976 (2024-002)

Material Weakness 2024

Dillard University

LA

Student Financial Aid Questioned Costs Matching / Level of Effort / Earmarking

The University acknowledges the enrollment status reporting errors noted in the audit. This was due to a lack of coordination between departments responsible for enrollment status updates and NSLDS reporting. Under the direction of the interim Controller, the University will work with Registrar, Off...

The University acknowledges the enrollment status reporting errors noted in the audit. This was due to a lack of coordination between departments responsible for enrollment status updates and NSLDS reporting. Under the direction of the interim Controller, the University will work with Registrar, Office of Records and Registrations to implement a monthly reconciliation process and establish clear ownership of status reporting responsibilities. A tracking log will be introduced to monitor timely and accurate submissions. Completion of corrective actions is expected by March 31, 2026.

View Audit 361246

Finding 569970 (2024-003)

Significant Deficiency 2024

City of Marco Island

FL

Questioned Costs Subrecipient Monitoring Cash Management § 200.302 § 200.303

DEPARTMENT OF HOMELAND SECURITY Disaster Grant Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend that the organization implement a review and approval process for all quarterly progress submissions. This should include: Training sta...

DEPARTMENT OF HOMELAND SECURITY Disaster Grant Public Assistance (Presidentially Declared Disasters) - Assistance Listing No. 97.036 Recommendation: We recommend that the organization implement a review and approval process for all quarterly progress submissions. This should include: Training staff on the importance of the review and approval process. Ensuring adequate staffing levels to handle the review process. Developing clear guidelins and procedures for the review and approval process. Regularly monitoring and auditing the review process to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The City will implement a review and approval process for all quarterly progress report submissions within it ERP (Enterprise Resource Planning) software system. The City will train its staff on the importance of the review and approval process. The City will ensure adequate staffing levels to handle the review process. The City will develop clear guidelines and procedures for the review and approval process. The City will regularly monitor and audit the reivew process to ensure compliance. Name(s) of the contact person(s) for corrective action: Guillermo Polanco. Planned completion date for corrective action plan: 09/30/2025

View Audit 361239

Finding 569954 (2024-002)

None 2024

Skokie School District #68

IL

Questioned Costs School Nutrition Programs

Finding Synopsis: One of 40 students selected for testing received free or reduced meals without having an application on file. Action Steps: Management will establish and reinforce procedures to ensure all applications are retained (paper and digital copies). Contact Person: Kenya Austin Asst. Supe...

Finding Synopsis: One of 40 students selected for testing received free or reduced meals without having an application on file. Action Steps: Management will establish and reinforce procedures to ensure all applications are retained (paper and digital copies). Contact Person: Kenya Austin Asst. Superintendent of Business/CSBO 847-568-7632 Anticipated Completion Date: 6/30/2025

View Audit 361197

Finding 569953 (2024-001)

None 2024

Skokie School District #68

IL

Questioned Costs

Finding Synopsis :Expenditure reports were submitted to ISBE after the due date. Action Steps :Management will establish and reinforce procedures to ensure all grant reports are submitted by the required due date. Contact Person: Kenya Austin, Asst. Superintendent of Business/CSBO 847-568-7632 Antic...

Finding Synopsis :Expenditure reports were submitted to ISBE after the due date. Action Steps :Management will establish and reinforce procedures to ensure all grant reports are submitted by the required due date. Contact Person: Kenya Austin, Asst. Superintendent of Business/CSBO 847-568-7632 Anticipated Completion Date: 6/30/2025

View Audit 361197

Finding 569951 (2024-004)

Material Weakness 2024

Idaho Immunization Coalition, Inc.

ID

Questioned Costs Allowable Costs / Cost Principles § 200.210 § 200.331

THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD...

THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.

View Audit 361196 Questioned Costs: $1

Finding 569942 (2024-001)

Significant Deficiency 2024

Berrien County Board of Education

GA

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.303 § 200.318 § 200.320 § 200.403

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: ...

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1099 (Year: 2024), 245GA324N1199 (Year: 2024) Questioned Costs: $77,285 Prior Year Finding: FA 2023-001 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were reviewed and approved and that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: Berrien will look at the current procedures for expenditures and make sure that every program is following the same protocols. We have a system in place to ensure that we can check suspension and debarment. Also, we have protocols in place to make sure all contracts are current. Estimated Completion Date: 9/30/2025 Contact Person: Jamie Taylor, Finance Director Telephone: 229-686-2081 Email: jamie.taylor@berrien.k12.ga.us

View Audit 361188 Questioned Costs: $1

Finding 569941 (2024-001)

Significant Deficiency 2024

Safe Haven Family Shelter, Inc.

TN

Allowable Costs / Cost Principles Questioned Costs Cash Management

Department of Health and Human Services Nashville Safe Haven Family Shelter, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024 through December 31, 2024 The findings from the schedule of findings and questioned costs are...

Department of Health and Human Services Nashville Safe Haven Family Shelter, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024 through December 31, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2024-001 Temporary Assistance for Needy Families – Assistance Listing No. 93.558 Recommendation: We recommend that management compares the mileage reimbursement per the grant allocation worksheets to the mileage reimbursement register to ensure only expenses incurred is being allocated to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Safe Haven will only change mileage reimbursement rates each year at the beginning of a calendar month, since allocations are calculated based on a single mileage rate for the month. Furthermore, Safe Haven will work with our Salesforce consultants to ensure the mechanism used to allocate staff costs is accurately programmed to calculate costs not to exceed actual amounts paid. Lastly, we will make it practice to compare the mileage reimbursement per the grant allocation worksheets to the mileage reimbursement register each month before completion of invoicing. Name(s) of the contact person(s) responsible for corrective action: Ben Piñon, Finance Director. Planned completion date for corrective action plan: August 2025 If the US Department of Health and Human Services has questions regarding this plan, please call Ben Piñon at 615-256-8195 ext. 125.

View Audit 361187 Questioned Costs: $1

Finding 569935 (2024-005)

Material Weakness 2024

International Fresh Produce Association

DC

Questioned Costs Reporting Matching / Level of Effort / Earmarking

The organization team has taken the action of setting up calendar reminders when all grant reports are due, and the information required to complete that report. Calendar notifications have also been made in the two weeks prior to the due date of all reporting requirements to serve as a reminder to ...

The organization team has taken the action of setting up calendar reminders when all grant reports are due, and the information required to complete that report. Calendar notifications have also been made in the two weeks prior to the due date of all reporting requirements to serve as a reminder to staff to compile the necessary information to submit reports in a timely manner.

View Audit 361183

Finding 569933 (2024-002)

Material Weakness 2024

International Fresh Produce Association

DC

Allowable Costs / Cost Principles Reporting Questioned Costs

Management has implemented a review process over the hours submitted by staff for specific grant work on 05/01/2025. The Chief Science Officer (CSO) will review and sign off on the hours submitted which form the basis of the salaries and benefit reimbursement(s). The Finance Director computes the sa...

Management has implemented a review process over the hours submitted by staff for specific grant work on 05/01/2025. The Chief Science Officer (CSO) will review and sign off on the hours submitted which form the basis of the salaries and benefit reimbursement(s). The Finance Director computes the salaries and benefits allowance along with the indirect costs per the award budget and the hours submitted. The Chief Finance Officer will review the salary, benefit and indirect computations prior to submitting a reimbursement request.

View Audit 361183

Finding 569931 (2024-001)

None 2024

Skokie School District 73.5

IL

Questioned Costs Reporting

The District will implement a process to track the submission time of the data collection form and audit package.

View Audit 361175

Finding 569928 (2024-001)

None 2024

Chinatown Manpower Project, INC

NY

Questioned Costs Reporting

CMP will take the following actions to ensure timely submission in future years: • Submit the 2024 DCF within five ( 5) business days of receiving the final audit report. 30 • Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. • Im...

CMP will take the following actions to ensure timely submission in future years: • Submit the 2024 DCF within five ( 5) business days of receiving the final audit report. 30 • Coordinate earlier with the external audit firm to establish mutually agreed-upon deadlines for key audit deliverables. • Implement an internal calendar to track critical reporting dates and milestones, beginning with the FY2025 audit cycle. • Assign a dedicated staff member to monitor audit progress and communicate regularly with the audit team to avoid last-minute delays.

View Audit 361170

Finding 569861 (2024-001)

None 2024

Center for Innovative Public Health Research

CA

Questioned Costs § 200.516

The entity has implemented wording in their vendor contracts that they will not honor invoices that are more than 90 days out.

View Audit 361128

Finding 569858 (2024-002)

Material Weakness 2024

Impact Community Action Partnership, Inc.

IA

Questioned Costs

Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The corrective action plan outlined in the 2023 audit was followed and the board has had the appropriate balance of low-income members since July, 2024...

Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The corrective action plan outlined in the 2023 audit was followed and the board has had the appropriate balance of low-income members since July, 2024.

View Audit 361122

Corrective Action Plans

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