Corrective Action Plans

Finding 568870 (2023-003)

Significant Deficiency 2023

MI

Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303

Reporting Significant Deficiency in Internal Control over Compliance Department of Treasury Federal Assistance Listing #21.027 Coronavirus State and Loan Fiscal Recovery Funds Finding Summary: Lack of documentation of a secondary review on expense reports required to be submitted. Responsible Indivi...

Reporting Significant Deficiency in Internal Control over Compliance Department of Treasury Federal Assistance Listing #21.027 Coronavirus State and Loan Fiscal Recovery Funds Finding Summary: Lack of documentation of a secondary review on expense reports required to be submitted. Responsible Individuals: Eric Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to ensure that a secondary review of expense report is taking place prior to submission and that those reviews are formally documented. Anticipated Completion Date: Ongoing

View Audit 360609

Finding 568813 (2023-006)

Significant Deficiency 2023

Northern Lakes Community Mental Health

MI

Subrecipient Monitoring Cash Management Reporting § 200.303

Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Cor...

Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Corrective Action: The CFO or Finance Manager will ensure that all cash requests are approved by the proper individuals. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24

View Audit 360525

Finding 568812 (2023-005)

Material Weakness 2023

Northern Lakes Community Mental Health

MI

Reporting Subrecipient Monitoring Cash Management § 200.328

Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-005 Reporting Condition: The CMHSP did not reconcile financial expenditures shown in the Federal Financial Report to the total disbursement and charges in PMS. Planned Corrective Action: The CFO or Finance Manager will ensure ...

Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-005 Reporting Condition: The CMHSP did not reconcile financial expenditures shown in the Federal Financial Report to the total disbursement and charges in PMS. Planned Corrective Action: The CFO or Finance Manager will ensure that the financial expenditures shown in the Federal Financial Report reconciles to the total disbursement and charges in PMS. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24

View Audit 360525

Finding 567967 (2023-001)

Significant Deficiency 2023

Community Action Partnership of Providence County

RI

Reporting Matching / Level of Effort / Earmarking

Finance team has hired an experience finance supervisor to help improve monthly and year end closing process, so organization can meet all its filing requirements without delays.

View Audit 360311

Finding 567928 (2023-004)

None 2023

Appalachian Headwaters INC

WV

Questioned Costs Reporting § 200.512

Management stated they intend to complete and submit all future audits prior to the required deadline. Management stated the failure was due solely to delays by the auditor. The auditor disagrees with this assertion, based upon the audit timeline evidenced in the audit documentation.

View Audit 360261

Finding 567927 (2023-003)

Significant Deficiency 2023

Appalachian Headwaters INC

WV

Questioned Costs Procurement, Suspension & Debarment Allowable Costs / Cost Principles § 200.430

Management stated they will purchase a professional time tracking software program to help all employees track their work hours and activities.

View Audit 360261 Questioned Costs: $1

Finding 567926 (2023-002)

Significant Deficiency 2023

Appalachian Headwaters INC

WV

Questioned Costs Reporting

Management stated that they disagree with the audit finding. Management notes that all expenses are documented in spreadsheets, invoice form, and available for review. However, management indicates that it will begin reclassifying federal grant expenditures in the accounting software. Auditor notes ...

Management stated that they disagree with the audit finding. Management notes that all expenses are documented in spreadsheets, invoice form, and available for review. However, management indicates that it will begin reclassifying federal grant expenditures in the accounting software. Auditor notes that this is consistent with the auditor’s finding that the entity lacks a means to efficiently determine that expenses charged to the grant are included in the general ledger, and the auditor’s recommendation to consider incorporating a chart of accounts specifically used for federal grant expenditures.

View Audit 360261

Finding 566907 (2023-006)

Material Weakness 2023

City of Compton

CA

HUD Housing Programs Internal Control / Segregation of Duties Special Tests & Provisions § 200.303

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new grants policy. The City Manager shall review and approve it for implementation by September 2025. Planned Implementation Date:...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The recommendations are included in the new grants policy. The City Manager shall review and approve it for implementation by September 2025. Planned Implementation Date: September 2025 Responsible Person(s): City Manager

View Audit 359774

Finding 566905 (2023-004)

Material Weakness 2023

City of Compton

CA

HUD Housing Programs Subrecipient Monitoring Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller’s Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller’s Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: September 2025 Responsible Person(s): City Manager, City Controller, and Community Development Director

View Audit 359774

Finding 566036 (2023-003)

Material Weakness 2023

West Burlington Independent School District

IA

Internal Control / Segregation of Duties Reporting

We will review our procedures and implement changes to improve internal control, as we deem necessary.

View Audit 359688

Finding 566032 (2023-001)

Material Weakness 2023

Horizon Health Services, Inc. and Affiliates

NY

Reporting

Re: The Horizon Corporations Report on Internal Control over Compliance for Federal Programs Dopkins & Company, LLP completed an updated report on internal control over financial reporting and on compliance and other matters based on an audit of combined financial statements performed in accordance...

Re: The Horizon Corporations Report on Internal Control over Compliance for Federal Programs Dopkins & Company, LLP completed an updated report on internal control over financial reporting and on compliance and other matters based on an audit of combined financial statements performed in accordance with Government Auditing Standards for federal programs for the operating period January 1, 2023 to December 31, 2023. Upon completion of the audit procedures, one finding was identified. The following is a response to this finding: Finding: The Companies' internal control over review of the Schedule of Expenditures of Federal Awards failed to detect $1,224,086 of federal award expenditures. The Companies should enhance their internal controls over intake and tracking of grants, including identification of federal awards, to produce a complete and accurate Schedule of Expenditures of Federal Awards. Horizon Response: In response to the finding, Horizon updated our procedures regarding completion of the Schedule of Expenditures of Federal Awards to the following: begin with the prior year audited schedule, update continuing awards with current year expenditures, remove concluded awards, and add new program expenditures. New programs will be identified via an internal tracking spreadsheet of all awards that will be updated monthly throughout the year by the Finance Manager and reviewed by the VP of Finance. This tracking spreadsheet will include funding source and, where applicable, CFDA/ ALN designations. At year end, this tracking spreadsheet will be reconciled to the SEFA.

View Audit 359678

Finding 565829 (2023-102)

Material Weakness 2023

Human Services Campus, INC

AZ

Reporting Cash Management Matching / Level of Effort / Earmarking

Finding 2023-102 - Grants and contracts - Identification of expenses and reconciliation and analysis Determination - Material Weakness in Internal Controls over Compliance Responsible Party: Ervin Reed, Director of Finance Anticipated Completion Date: September 30, 2025 Planned Action: Designed a ...

Finding 2023-102 - Grants and contracts - Identification of expenses and reconciliation and analysis Determination - Material Weakness in Internal Controls over Compliance Responsible Party: Ervin Reed, Director of Finance Anticipated Completion Date: September 30, 2025 Planned Action: Designed a cost center structure where program direct and indirect costs are tagged. Additionally, identify all relevant funding sources for each program. Configure the accounting system (Quickbooks for FY24 and NetSuite for FY25) to use multiple segments to track both revenue and expenses - one segment for program, one segment for funding source. An 'unfunded' code will be used to capture costs not billable to specific grants.

View Audit 359538

Finding 565827 (2023-101)

Significant Deficiency 2023

Human Services Campus, INC

AZ

Cash Management Reporting HUD Housing Programs

Finding 2023-101 - Grants and Contracts - Identification of expenses and reconciliation Determination - Significant Deficiency in Internal Controls over Compliance & Allowable CostsResponsible Party: Ervin Reed, Director of Finance Anticipated Completion Date: September 30, 2025 Planned Action: Des...

Finding 2023-101 - Grants and Contracts - Identification of expenses and reconciliation Determination - Significant Deficiency in Internal Controls over Compliance & Allowable CostsResponsible Party: Ervin Reed, Director of Finance Anticipated Completion Date: September 30, 2025 Planned Action: Designed a cost center structure where program direct and indirect costs are tagged. Additionally, identify all relevant funding sources for each program. Configure the accounting system (Quickbooks for FY24 and NetSuite for FY25) to use multiple segments to track both revenue and expenses - one segment for program, one segment for funding source. An 'unfunded' code will be used to capture costs not billable to specific grants.

View Audit 359538

Finding 565826 (2023-002)

Material Weakness 2023

My Project USA

OH

Reporting Internal Control / Segregation of Duties

Federal Audit Clearinghouse Filing – My Project USA recognizes the importance of timely filing of the Federal Audit Clearinghouse report. To address this issue, Uzair Qidwai, Ramy El- Asal, and Executive Director Zerqa Abid will ensure the audit is completed promptly and the reporting is done within...

Federal Audit Clearinghouse Filing – My Project USA recognizes the importance of timely filing of the Federal Audit Clearinghouse report. To address this issue, Uzair Qidwai, Ramy El- Asal, and Executive Director Zerqa Abid will ensure the audit is completed promptly and the reporting is done within the specified timeframe.

View Audit 359537

Finding 565825 (2023-001)

Material Weakness 2023

My Project USA

OH

Material Weakness Reporting Equipment & Real Property Management

Prior Period Restatement – My Project USA acknowledges the importance of accurately reporting transactions within the appropriate accounting periods and recognizes the internal control weaknesses that contributed to this finding. To address this issue, Uzair Qidwai, Ramy El-Asal, and Executive Direc...

Prior Period Restatement – My Project USA acknowledges the importance of accurately reporting transactions within the appropriate accounting periods and recognizes the internal control weaknesses that contributed to this finding. To address this issue, Uzair Qidwai, Ramy El-Asal, and Executive Director Zerqa Abid will review the organization's processes and internal controls to ensure they are up-to-date and robust enough to instill full confidence in the organization's ability to report transactions in a timely and accurate manner. Additionally, new measures will be implemented to provide a comprehensive overview of all grants, thereby enhancing the understanding of the overall grant environment.

View Audit 359537

Finding 565802 (2023-002)

Significant Deficiency 2023

Substance Abuse Services, Inc.

PA

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.430

View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and...

View of Responsible Official Currently, the Organization’s CEO and the bookkeeper will review each grant’s funding details prior to the grant’s fiscal year to determine how each employee’s salary percentages should be allocated according to the grant contract. Throughout the fiscal year, the CEO and bookkeeper will meet regularly to review and incorporate any new hires to determine how their salary is expected to be allocated. Additionally, the outsourced accountant will review the allocations periodically throughout the year to ensure that it is being done properly. Over the next year, as considered efficient, the Organization will implement a daily timesheet record, which requires each program service employee to classify their daily time between federal grant programs. At the end of each week, staff members will submit their timesheet to their supervisor. The supervisor will review each week’s daily timesheet to confirm the staff are recognizing their activities properly. At the end of each month, the Organization’s outsourced accountant, will review these timesheets and determine the proper allocation needed to record each employee’s payroll activities in the accounting software by appropriate federal program. This process will allow for the allocation of actuals to each federal program by the end of the month.

View Audit 359497

Finding 565773 (2023-001)

Material Weakness 2023

Community Counseling Centers of Chicago, Inc. and Affiliate

IL

Reporting

Finding 2023-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 21.027 Coronavirus State and Local Fiscal Recovery Funds Federal Agency U.S. Department of Health and Human Services and U.S. Depar...

Finding 2023-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 21.027 Coronavirus State and Local Fiscal Recovery Funds Federal Agency U.S. Department of Health and Human Services and U.S. Department of Treasury Award Number/Year 2023 Criteria C4 has grant agreements from Federal agencies and State of Illinois agencies with terms requiring compliance with financial reporting requirements in accordance with Uniform Guidance and the State of Illinois Grant Accountability and Transparency Act (GATA). As such, for the year ended June 30, 2023, C4 is required to submit audited financial statements, a schedule of expenditures of federal awards (SEFA) and single audit reports to the Federal Audit Clearinghouse and the same audit package plus a Consolidated Year End Financial Report (CYEFR) to the GATA portal. All items are required to be submitted to the GATA portal within six (6) months after C4’s fiscal year-end and to the Federal Audit Clearinghouse within nine (9) months after C4’s fiscal year-end. Views of Responsible Officials and Planned Corrective Actions Management concurs with the auditor’s finding and will implement the recommended corrective action. Person(s) responsible: Katherine Maitha, Controller Date of Anticipated Completion Date: March 2026

View Audit 359463

Finding 565410 (2023-004)

Significant Deficiency 2023

House of Hope Community Development Corporation

RI

Reporting § 200.512

Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor’s finding and recommendation. The new Deputy Director of Finance will play a key role in ensuring adherence to audit timelin...

Recommendation: Implement procedures and controls to ensure that future audits are completed and submitted in a timely manner. Action Taken: Management agrees with the auditor’s finding and recommendation. The new Deputy Director of Finance will play a key role in ensuring adherence to audit timelines and enhancing overall reporting efficiency.

View Audit 359280

Finding 565409 (2023-003)

Significant Deficiency 2023

House of Hope Community Development Corporation

RI

Questioned Costs Reporting Internal Control / Segregation of Duties § 200.303 § 200.334

Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Dire...

Recommendation: Implement enhanced procedures for the systematic maintenance and retrieval of all financial records related to expenditures, including staff training on these protocols. Action Taken: Management agrees with the auditor’s finding and recommendation. The newly appointed Deputy Director of Finance will oversee the implementation of these enhanced procedures.

View Audit 359280

Finding 565379 (2023-001)

Material Weakness 2023

Arisa Health INC

AR

Questioned Costs Reporting Internal Control / Segregation of Duties

U.S. Department of Health and Human Services Federal Assistance Listing Number 93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Responsible Party: Brian Lutz, Vice President of Accounting Estimated Completion Date: December 2024 Issue Counseling Associates, Inc. (CAI) re...

U.S. Department of Health and Human Services Federal Assistance Listing Number 93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Responsible Party: Brian Lutz, Vice President of Accounting Estimated Completion Date: December 2024 Issue Counseling Associates, Inc. (CAI) reported $375,083.37 in ‘Total Reportable Other PRF Expenses’ on its Phase 4 Provider Relief Fund (PRF) Report covering the period July 1, 2021-December 31, 2021. CAI’s intent was for the entire $992,263.30 in total reportable PRF payments to be applied to lost revenues. The $375,083.37 amount reported in the Other PRF Expenses section of the report represented allowable expenditures for funding received through the Arkansas Workforce Stabilization Incentive Program funded through Section 9817 of the America Rescue Plan Act. The reporting error was due to the misinterpretation of the form by both the preparer and approver that Total Reportable Other PRF Expenses was an accounting for the use of funds reported in the ‘Other Assistance Received’ section immediately preceding this section. Corrective Action This report was prepared by the Vice President of Accounting and reviewed and approved prior to submission by the Chief Financial Officer. The approval process is deemed to be adequate by management but failed in this case due to the preparer and approver committing the same misinterpretation and overlooking the accounting provided in the ‘Other PRF Summary’ section of the report. The preparer and approver will both apply a corrected understanding and perform a more thorough review of future PRF reports.

View Audit 359232

Finding 565369 (2023-001)

Significant Deficiency 2023

Blount Memorial Hospital, Inc.

TN

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Management concurs with the recommendation as proposed and is implementing policies and procedures to track and monitor reporting requirements. Management will file the reporting package and data collection form.

View Audit 359209

Finding 565361 (2023-001)

Material Weakness 2023

Mid-Michigan Community Action Agency, Inc.

MI

Questioned Costs Material Weakness Reporting

Finding 2023-001: Internal Control Over Financial Reporting Management’s Response Mid Michigan CAA has a long-standing history of exemplary stewardship of federal, state, and local funds. The significant delay in preparation and subsequent completion of the FY2023 audit is directly related to staf...

Finding 2023-001: Internal Control Over Financial Reporting Management’s Response Mid Michigan CAA has a long-standing history of exemplary stewardship of federal, state, and local funds. The significant delay in preparation and subsequent completion of the FY2023 audit is directly related to staffing issues within the agency’s finance department. To prevent recurrence of this issue, Mid Michigan CAA is implementing the following corrective actions: 1. Revised Internal Timeline: We have established an internal audit preparation calendar with clearly defined deadlines to ensure timely completion and submission of future audits. 2. Enhanced Oversight: The Finance Committee of the Board will now receive monthly updates on audit progress during the audit cycle to ensure accountability and timely resolution of any issues. 3. Staff Engagement: Key finance staff are provided with more context and information on the audit process so that they can be more engaged and able to assist in the data gathering process. Contact Person Responsible for Corrective Action: Mark Polega, Executive Director Anticipated Completion Date: February 2025 – September 2025

View Audit 359207

Finding 565359 (2023-003)

Significant Deficiency 2023

Women's Center for Advancement

NE

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

Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will ...

Condition: Certain underlying support related to the VOCA Victim Assistance Formula Grant did not agree to amounts charged to the grant. Supporting information and records indicated more funds were spent by the Organization than were charged to the grant. Planned Corrective Action: Management will review its processes, procedures and controls to ensure that reconciliation and review of grant reimbursement requests and supporting underlying documentation occurs in future periods. Planned Completion Date: Ongoing Person Responsible: Kim Reed, VP of Finance

View Audit 359201

Finding 565326 (2023-003)

Significant Deficiency 2023

The Wayside House, Inc. and Subsidiary

MN

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring § 200.303

Management agrees with the auditors' finding and will take action to implement controlling procedures over federal programs. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Accounting Specialist, Alex Sukalski, Chief Financial Officer

View Audit 359149

Finding 565301 (2023-004)

Material Weakness 2023

City of Madison

IN

Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.1 § 200.303

FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regardi...

FINDING 2023-004 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Mindy McGee Contact Phone Number and Email Address: 812-265-8300, mmcgee@madison-in.gov Views of Responsible Officials: We concur with the finding regarding errors in Coronavirus Fund reporting. Description of Corrective Action Plan: Historically, the city has not had a centralized position who would be responsible for grant compliance and reporting. Individual department heads were responsible for comp0lying with each awarded grant for their own area of responsibility. In spring of 2025, a new Project & Grant Manager position was created and filled by a qualified individual. The responsibilities of the position include data collection and analysis, project management, grant coordination, information management and compliance monitoring and reporting. Anticipated Completion Date: The new position referenced above has been filled and is in operation as of April 8th 2025.

View Audit 359138

Corrective Action Plans

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