Corrective Action Plans

Finding 1218486 (2025-056)

Material Weakness 2025

State of Michigan

MI

Reporting Matching / Level of Effort / Earmarking § 200.303

Finding 2025-056 WIOA Cluster, ALN 17.258, 17.259, and 17.278 Management Views LEO agrees with the finding. LEO management recognizes the importance of timely and accurate FFATA reporting and acknowledges that internal processes can be strengthened to better support reporting consistency, particular...

Finding 2025-056 WIOA Cluster, ALN 17.258, 17.259, and 17.278 Management Views LEO agrees with the finding. LEO management recognizes the importance of timely and accurate FFATA reporting and acknowledges that internal processes can be strengthened to better support reporting consistency, particularly during high-volume periods such as quarter-end. LEO remains committed to compliance and continuous improvement. Planned Corrective Action LEO will improve existing FFATA reporting processes by reinforcing internal timelines, clarifying staff responsibilities, and implementing an additional review step prior to submission to help ensure subaward information is reported timely and accurately. Management will train appropriate staff responsible for FFATA reporting to strengthen understanding of reporting requirements, deadlines, and review expectations. These improvements are intended to enhance process consistency, improve communication, and reduce the likelihood of future timing or minor reporting discrepancies. LEO will enhance documented procedures that outline specific FFATA reporting processes related to the Workforce Innovation and Opportunity Act (WIOA). Anticipated Completion Date September 30, 2026 Responsible Individual(s) Arica Johnson, LEO

View Audit 404775

Finding 1218483 (2025-012)

Material Weakness 2025

State of Michigan

MI

Questioned Costs Reporting Internal Control / Segregation of Duties

Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Con...

Finding 2025-012 SNAP Cluster, ALN 10.551 and 10.561 and Summer Electronic Benefits Transfer Program for Children, ALN 10.646 - System and Organization Controls Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is currently evaluating the two System and Organization Controls (SOC) reports and will document the evaluation and determination of whether a review is required. Based on these evaluations, if MDHHS determines reviews are required, MDHHS will document the SOC report reviews by June 30, 2026. Also, MDHHS will assess the current SOC review process and implement any needed improvements to ensure subservice organizations are properly evaluated, formally documented, and that SOC report reviews are submitted within 60 days of receiving each report, by September 30, 2026. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Tony Weber, MDHHS Veronica Maxson, MDHHS Dani Wager, MDHHS Tim Kubu, MDHHS

View Audit 404775

Finding 1218448 (2025-006)

Material Weakness 2025

Crazy Horse School

SD

Questioned Costs Reporting Internal Control / Segregation of Duties

#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The...

#2025-006 FINDING: Reporting Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will reconcile individual program expenditure activity to the completed SF425 report and establish deadlines for filing submissions within the grant agreement timelines. The Business Manager will follow the recommendation of the auditor. Anticipated Completion Date: Ongoing

View Audit 404724

Finding 1218436 (2025-003)

Material Weakness 2025

Crazy Horse School

SD

Cash Management Period of Performance Reporting

#2025-003 FINDING: Grant Tracking Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will follow the recommendation of the auditors. This expenditure of the Curriculum Subscription was paid for the first year to get started with the material, we did not...

#2025-003 FINDING: Grant Tracking Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: The Business Manager will follow the recommendation of the auditors. This expenditure of the Curriculum Subscription was paid for the first year to get started with the material, we did not expense it in the second and third year. A discount was given to pay the three years up front. The prepaid upfront expense was approved by the grantor. The Business Manager will continue to agree that actual expenditures incurred to the general ledger before requesting reimbursement. Anticipated Completion Date: Ongoing

View Audit 404724

Finding 1218435 (2025-002)

Material Weakness 2025

Crazy Horse School

SD

Reporting

#2025-002 FINDING: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation and Audit Adjustments Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: Management of the School has reviewed the financial statements and schedule of expenditures of fe...

#2025-002 FINDING: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation and Audit Adjustments Responsible Individual: Pedro Rosa, Business Manager Corrective Action Plan: Management of the School has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the School. Management and the Board has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Crazy Horse School Business Office staff will follow auditor’s recommendation. Anticipated Completion Date: Ongoing

View Audit 404724

Finding 1218417 (2025-001)

Material Weakness 2025

Booth Residence Inc., A Georgia Corporation

GA

Questioned Costs Reporting

Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory ...

Project Legal Name: Booth Residence, Inc., A Georgia Corporation HUD Project No.: 061-11293 Audit Firm: CohnReznick LLP Period covered by the audit: 10/01/24-9/03/25 (day before sale) Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and notes that the property was sold on September 4, 2025 to an unrelated party, therefore we consider this finding closed and no further action required.

View Audit 404684

Finding 1218415 (2025-005)

Material Weakness 2025

Evangeline Booth Residence, Inc., A Florida Corporation

FL

Questioned Costs Reporting

5. Finding 2025-005 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...

5. Finding 2025-005 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.

View Audit 404683

Finding 1218414 (2025-004)

Material Weakness 2025

Evangeline Booth Residence, Inc., A Florida Corporation

FL

HUD Housing Programs Eligibility Reporting

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedur...

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to continue to follow up with HUD to complete activation of their EIV system access. Once access is established, management should implement procedures to ensure all required EIV reports are generated, retained, and reviewed in accordance with HUD guidelines. b. Action(s) Taken or Planned on the Finding Management acknowledged the challenges experienced in obtaining EIV access from HUD and stated that follow-up efforts are ongoing. Once access is granted by HUD as already approved, management will generate and maintain all required EIV reports and strengthen controls to ensure compliance with HUD requirements.

View Audit 404683

Finding 1218404 (2025-002)

Material Weakness 2025

The Salvation Army Residence Inc., A Florida Corporation

FL

HUD Housing Programs Reporting

Project Legal Name: The Salvation Army Residences, Inc., A Florida Corporation HUD Project No.: 067-11269 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2024 – 6/30/2025 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory...

Project Legal Name: The Salvation Army Residences, Inc., A Florida Corporation HUD Project No.: 067-11269 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/2024 – 6/30/2025 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.

View Audit 404682

Finding 1218393 (2025-003)

Material Weakness 2025

Catherine Booth Residence INC A Florida Corporation

FL

Questioned Costs Reporting

3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...

3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.

View Audit 404679

Finding 1218388 (2025-002)

Material Weakness 2025

Evangeline Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Reporting

2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...

2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.

View Audit 404678

Finding 1218387 (2025-001)

Material Weakness 2025

Evangeline Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Special Tests & Provisions HUD Housing Programs

Project Legal Name: Evangeline Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113- EE041 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Te...

Project Legal Name: Evangeline Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113- EE041 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the project for overpaid management fee in the amount of $466 and implement procedures to ensure that the management fee paid does not exceed the amount determined in accordance with the management agreement. b. Action(s) Taken or Planned on the Finding Management will repay the property and update our procedures to correctly calculate management fees.

View Audit 404678

Finding 1218383 (2025-004)

Material Weakness 2025

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Special Tests & Provisions Cash Management

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the amount due to the project and establish procedures to ensure reimbursement for shared costs and related receivables are made timely ...

4. Finding 2025-004 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to reimburse the amount due to the project and establish procedures to ensure reimbursement for shared costs and related receivables are made timely in accordance with established policy. b. Action(s) Taken or Planned on the Finding We will implement procedures to ensure shared costs are reimbursed on a consistent and regular basis.

View Audit 404677

Finding 1218382 (2025-003)

Material Weakness 2025

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Reporting

3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s)...

3. Finding 2025-003 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period.

View Audit 404677

Finding 1218381 (2025-002)

Material Weakness 2025

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Special Tests & Provisions HUD Housing Programs

2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to deposit $21,146 into the replacement reserve account or obtain evidence of HUD approval. b. Action(s) Taken or Planned on the Finding Management a...

2. Finding 2025-002 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to deposit $21,146 into the replacement reserve account or obtain evidence of HUD approval. b. Action(s) Taken or Planned on the Finding Management acknowledges that two replacement reserve withdrawals dated February 14, 2025 were processed prior to obtaining HUD's written approval. This occurred due to a temporary lapse in oversight during a staff absence. We will attempt to retroactively obtain HUD approval for the withdrawal.

View Audit 404677

Finding 1218380 (2025-001)

Material Weakness 2025

Catherine Booth Friendship House Residence Inc., A Texas Corporation

TX

Questioned Costs Special Tests & Provisions Reporting

Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Terr...

Project Legal Name: Catherine Booth Friendship House Residence, Inc., A Texas Corporation HUD Project No.: 113-EE021 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure the funds are deposited into the correct account and to ensure that the replacement reserve is funded in accordance with the terms of the regulatory agreement. b. Action(s) Taken or Planned on the Finding North TX A/C refunded two months deposit of $5,464 to the property as of September 30, 2025. One month deposit was correctly deposited into the replacement reserve account, the second missed deposit was not deposited into the replacement reserve account. We will correct the deposit and move to the replacement reserve account.

View Audit 404677

Finding 1218375 (2025-001)

Material Weakness 2025

William Booth Residence Inc., A North Carolina Corporation

NC

Questioned Costs Reporting

Project Legal Name: William Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE107 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Fina...

Project Legal Name: William Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE107 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit within the 9-month period. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations None

View Audit 404676

Finding 1218373 (2025-001)

Material Weakness 2025

Catherine Booth Residence Inc., A North Carolina Corporation

NC

HUD Housing Programs Reporting

Project Legal Name: Catherine Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE131 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Fi...

Project Legal Name: Catherine Booth Residence, Inc., A North Carolina Corporation HUD Project No.: 053-EE131 Audit Firm: CohnReznick LLP Period covered by the audit: 10/1/24-9/30/25 Corrective Action Plan prepared by: Name: Philip Gesner Position: Financial Project Manager, USA Southern Territory Finance Department Telephone Number: 470-816-5977 A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation The auditee agrees with the finding. The auditee agrees with the recommendation to implement procedures to ensure that the financial statements are submitted to the FAC in accordance with the FAC filing requirements. b. Action(s) Taken or Planned on the Finding Management agrees with the finding and is taking steps to address the issue that caused it. Management was able to implement procedures to submit the 2025 audit in a timely manner. B. Status of Corrective Actions on Findings Reported in the Schedule of the Status of Prior Year Findings, Questioned Costs and Recommendations None

View Audit 404675

Finding 1218361 (2025-001)

Material Weakness 2025

Northwest Regional Airport Authority

MI

Reporting Internal Control / Segregation of Duties

Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and r...

Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and request reimbursement of federal funds. It shows how much of the grant has been spent (outlays) and how much reimbursement is being requested from the funding agency. SF-425 (Federal Financial Report) provides a comprehensive summary of the financial status of a grant, including total expenditures, federal funds used, recipient cost share (if applicable), and remaining balances, to ensure proper accountability and compliance with grant requirements. Although these reports were submitted after the established due dates, management maintained the reporting requirements as an active and ongoing priority. These reports were regularly discussed during monthly coordination meetings involving Airport staff and the FAA Airports District Office (ADO), as well as during weekly internal staff meetings. During these regular discussions with the FAA ADO, the Airport was not advised that it was out of compliance with reporting deadlines. Rather, the FAA consistently indicated that reports should be submitted as soon as practicable. The Airport remained aware of its reporting obligations and their importance, particularly in support of ongoing efforts to secure funding for the terminal expansion project. Notwithstanding the above, management acknowledges that formal tracking mechanisms and documented follow-up procedures can be strengthened to ensure earlier identification and resolution of incomplete or missing grant data. To address this, management will enhance internal controls over grant reporting to ensure timely and complete submissions. Improvements will include implementing calendar-based tracking tools and structured notification procedures, with reminders and follow-up communications beginning at the FAA fiscal year-end (September 30) and continuing through the reporting due date (December 31). Additionally, management will coordinate with the FAA and MDOT to secure reliable access to the FAA’s Delphi System, where the data necessary to complete these reports resides. Communication with both the FAA ADO and MDOT will be further strengthened during the critical period leading up to reporting deadlines to ensure that any missing or incomplete information is promptly identified and addressed. Regular internal discussions regarding grant reporting status will also continue to support timely resolution of outstanding items. Management believes these corrective actions will mitigate the risk of delayed or incomplete reporting and strengthen overall compliance with grant requirements. Responsible Party for Corrective Action: Mark Bishop, Chief Financial Officer Anticipated Completion Date: June 2026.

View Audit 404642

Finding 1218307 (2025-003)

Material Weakness 2025

Dona Ana County

NM

Questioned Costs Reporting § 200.512

Views of Responsible Officials and Planned Corrective Action Doña Ana County implemented Workday as new ERP system for the year ended June 30, 2025. There are several configuration issues and as a result, there has been a significant increase in the amount of time the county staff requires to provid...

Views of Responsible Officials and Planned Corrective Action Doña Ana County implemented Workday as new ERP system for the year ended June 30, 2025. There are several configuration issues and as a result, there has been a significant increase in the amount of time the county staff requires to provide information related to the audit. We posted RFP for Workday re-implementation, and the contract will go to the Board of County Commissioners for approval in April 2026. We will contract with an audit and accounting firm and will use their services to correct the implementation issues. That will help resolve the issues we faced in 2025 audit. The County’s Finance department had retirements and turnover in key audit-related positions. We will continue training and professional development of employees in current auditing and accounting standards. The County is establishing a centralized grant office and will consistently train the grant administrators that will affect grant accounting reconciliations and oversight. These steps will improve the timeliness and accuracy of financial reporting for audits and enable timely submission of reports. Finding resolution timeline: December 1, 2026 Designation of employee position responsible for meeting this deadline: Controller, Financial Services Director, Grants Manager, and IT Assistant Director

View Audit 404551

Finding 1218293 (2025-005)

Material Weakness 2025

Resilience: Advocates for Ending Violence

MI

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...

Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.

View Audit 404531

Finding 1218269 (2025-005)

Material Weakness 2025

TOWN OF HOPKINTON

RI

Questioned Costs Reporting

Corrective Action: Future reports relative to Federal agencies will rely solely upon general ledger details at the time of the reporting. Effort will be made to be as inclusive as possible. Anticipated Completion Date: Next reporting period Contact Person: Elizabeth Draper

View Audit 404527

Finding 1218262 (2025-002)

Material Weakness 2025

Five-Town Health Alliance, Inc. D/b/a Mountain Health Center

VT

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

Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a disco...

Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted four instances in which the sliding fee discount applied was inconsistent with the Organization’s policy. Three patients did not receive the appropriate discount and one patient received a discount but did not have an active sliding fee application for the service date the sliding fee discount was applied. Individual(s) Responsible for Corrective Action: Lori Slicer, Revenue Cycle Manager (organization-wide sliding fee discount monitoring procedure across the medical and dental service lines). Crystal Kinsman, Dental Practice Manager (dental-specific monitoring, with increased sampling of the Dental system given its higher level of manual processing). Heidi Melbostad, Chief Executive Officer and Compliance Officer (sliding fee discount schedule redesign and oversight). Planned Corrective Action: Management is addressing this finding through both an immediate interim action and a comprehensive redesign, together with an ongoing monitoring control. Interim action (completed): the Board approved revised nominal fee levels on 2026-04-27, effective 2026-04-28, establishing Category A as the most favorable discount category, consistent with Section 330(k)(3)(G) of the Public Health Service Act. Full corrective action: management will complete a comprehensive redesign of the Sliding Fee Discount Program, including separate schedules for the medical and dental service lines, data-driven evaluation of tier thresholds and fee levels, and replacement of the percentage-based payment option with a clearer flat-fee structure, for Board review and approval. Ongoing monitoring control: management will establish a documented monitoring procedure over sliding fee discount application across both the medical and dental service lines, including a defined monthly sample drawn from each service line with increased sampling of the Dental system given its higher level of manual processing, verification that an active sliding fee application is on file for each service date, documented review results, timely correction of identified errors, and supervisory sign-off, with error rates reviewed at least quarterly. Anticipated Completion Date: Interim nominal fee revision effective 2026-04-28 (completed). Comprehensive Sliding Fee Discount Program redesign and ongoing monitoring procedure to be Board-approved and operational by 2026-08-24.

View Audit 404523

Finding 1218248 (2025-001)

Material Weakness 2025

Valorus

CA

Reporting Internal Control / Segregation of Duties § 200.510

Finding 2025-001 – Accuracy of Schedule of Expenditures of Federal Awards (SEFA) The ALN numbers identified as incorrect were on 16.588 & 16.575 under the Violence Against Women Formula Grant. These two numbers were inadvertently transposed during preparation of the SEFA. Out of the 20 ALN numbers r...

Finding 2025-001 – Accuracy of Schedule of Expenditures of Federal Awards (SEFA) The ALN numbers identified as incorrect were on 16.588 & 16.575 under the Violence Against Women Formula Grant. These two numbers were inadvertently transposed during preparation of the SEFA. Out of the 20 ALN numbers reported, only these two were inaccurate. All expenditures reported on the SEFA were based on actual expenditures incurred consistent with prior guidance provided by the auditor. During the previous audit cycle, VALOR’s accountant sought clarification regarding whether expenditures should be reported based on actual expenditures or reimbursement amounts and was instructed to use actual expenditures incurred. In accordance with 2 CFR 200.510(b), auditees must prepare a SEFA that accurately identifies programs by the correct ALN and reports expenditures based on actual amounts expended from federal awards. Except for the inadvertent transposition of the two ALN numbers noted above, the SEFA was prepared in compliance with these requirements. As a corrective action, beginning with the next SEFA report for the 2025-2026 fiscal year, the SEFA will be prepared by the Senior Accountant, Karen Sayers, and reviewed by both the Director of Operations, Rosemary Gonzales, and the organization’s CPA, Kim Jones, prior to submission to verify the accuracy of all ALN numbers and reported amounts.

View Audit 404493

Finding 1218216 (2025-002)

Material Weakness 2025

Town of Castle Rock, Colorado

CO

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303 § 200.328 § 200.329

Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...

Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.

View Audit 404489

Corrective Action Plans

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