Corrective Action Plans

Finding 1155828 (2024-003)

Material Weakness 2024

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.

View Audit 368220 Questioned Costs: $1

Finding 1155768 (2024-001)

Material Weakness 2024

Wheeling Hospital, Inc.

WV

HUD Housing Programs Significant Deficiency

Contact Person: William Bane Management’s Response: Management acknowledges that there were not sufficient controls in place to ensure written consent from HUD prior to incurring new debt or lease arrangements. Four of the five leases in question were all entered into and approved by individuals no ...

Contact Person: William Bane Management’s Response: Management acknowledges that there were not sufficient controls in place to ensure written consent from HUD prior to incurring new debt or lease arrangements. Four of the five leases in question were all entered into and approved by individuals no longer with the organization and without prior knowledge of hospital finance personnel. Current Management had previously established controls to ensure written consent is obtained prior to incurring any new debt or lease arrangements, but these arrangements were not caught before being signed. The HUD loan was retired and refinanced with another financial institution during 2024 so this will not be an issue going forward. Completion Date: September 23, 2025

View Audit 368139

Finding 1155725 (2024-001)

Material Weakness 2024

The Housing Authority of the City of Greenville

SC

HUD Housing Programs Eligibility Significant Deficiency

The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and som...

The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. TGHA files were fully in order by July 2025.

View Audit 368012

Finding 1155700 (2024-001)

Material Weakness 2024

Xavier University

OH

Special Tests & Provisions Student Financial Aid Significant Deficiency

Corrective Action Plan Xavier complies with the loan disbursement notification rules. During the audit we learned that, while our system was sending the emails to each student with a loan disbursement, our process for copying each individual email to xufinaid was not functioning. Further, the notifi...

Corrective Action Plan Xavier complies with the loan disbursement notification rules. During the audit we learned that, while our system was sending the emails to each student with a loan disbursement, our process for copying each individual email to xufinaid was not functioning. Further, the notification report was being overwritten daily, causing us to lose the audit trail for these notifications. We have implemented two steps to be able to document each individual email. 1. The xufinaid@xavier.edu email address is copied on every disbursement notification and each notification email is delivered into the xufinaid inbox in Outlook. Every Wednesday those emails are moved by financial aid personnel into a folder in Outlook where they remain stored. This weekly review allows personnel to know in a timely manner if there are issues with the email delivery process. 2. A log file which saves a list of the disbursement notification emails is saved on a daily basis. It includes the content of each email.

View Audit 367993

Finding 1155694 (2024-003)

Material Weakness 2024

Milton Housing Authority

MA

HUD Housing Programs Special Tests & Provisions Significant Deficiency

September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-003 – Special Tests and Provisions; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Over the course of 2024, Milton Housing Authority worked on the creation o...

September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-003 – Special Tests and Provisions; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Over the course of 2024, Milton Housing Authority worked on the creation of a comprehensive HCV Administrative Plan. The Administrative Plan was approved by the Board on December 3, 2024, and Chapter 17 discusses the Mainstream program and program eligibility. It is the opinion of Milton Housing Authority that the matter has been resolved. Planned Implementation Date of Corrective Action: Completed Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169

View Audit 367971

Finding 1155693 (2024-002)

Material Weakness 2024

Milton Housing Authority

MA

HUD Housing Programs Reporting Significant Deficiency

September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-002 – Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Milton Housing Authority continues to develop better internal controls over the performance a...

September 24, 2025 MILTON HOUSING AUTHORITY CORRECTIVE ACTION PLAN Finding No. 2024-002 – Reporting; Significant Deficiency (HCV Cluster #14.871 and #14.879) Auditee’s Response and Planned Corrective Action Milton Housing Authority continues to develop better internal controls over the performance and documentation of SEMAP. There has been staff turnover and increased training will assist this staff member to better understand the process. Staff is working more closely with local HUD staff to better understand their expectations and protocol. Planned Implementation Date of Corrective Action: September 24, 2024 Person Responsible for Corrective Action: Earl Fay, Executive Director (617) 698-2169

View Audit 367971

Finding 1155683 (2024-002)

Material Weakness 2024

City of South Bend

IN

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct G...

Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct Grant Compliance Requirement: Special Tests and Provisions - Underwriting Requirements Audit Findings: Significant Deficiency Condition: The Consortium did not have a documented review control in place to ensure the underwriting calculation was prepared, reviewed, and maintained. Context: In a sample of three, the following items were noted: • For the first selection, project underwriting support was not available. The underwriting calculation was prepared by a former employee. Review of the calculation was also performed by a former employee. The Consortium does not have record of the calculation. • For the second selection, the underwriting calculation did not have formal sign off by the reviewer. Only the preparer signed the calculation. • For the third selection, the underwriting calculation did not have formal sign off by the preparer. Only the reviewer signed the calculation. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a system of internal controls to ensure the required underwriting calculations are prepared, reviewed, and maintained. Responsible Party and Timeline for Completion: The Consortium Director (or their designee) and the Federal Grant Administrator are responsible for implementation, which will go into effect immediately.

View Audit 367949

Finding 1155667 (2024-005)

Material Weakness 2024

Nobles County

MN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.403

2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Sign...

2024-005 Reporting Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that the Couty implement review procedures to ensure that the reports are submitted timely and accurately, and record of review is kept on file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025.

View Audit 367943 Questioned Costs: $1

Finding 1155666 (2024-004)

Material Weakness 2024

Nobles County

MN

Allowable Costs / Cost Principles Eligibility Significant Deficiency § 200.403

2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Fin...

2024-004 Review of Casefiles Federal Agency: U.S. Department of Human Services Federal Program Name: Medical Assistance Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2405MN5ADM, 2405MN5MAP; 2024 Pass-Through Agency: Minnesota Department of Human Services Type of Finding: Significant Deficiency in Internal Control over Compliance Award Period: Year Ended December 31, 2024 Recommendation: It is recommended that a supervisor or team lead perform regular internal reviews on MAXIS and METS casefiles to determine that proper policies and procedures are being followed in determining eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action: Stacie Golomiecki, Community Services Director – Stephani Diekmann, Fiscal Supervisor Planned completion date for corrective action plan: December 31, 2025

View Audit 367943

Finding 1155663 (2024-001)

Material Weakness 2024

Cahaba Medical Care Foundation

AL

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of tim...

2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss

View Audit 367937

Finding 1155651 (2024-001)

Material Weakness 2024

The National Dry Bean Council Incorporated

OR

Internal Control / Segregation of Duties Significant Deficiency § 200.303

FINDING 2024-001 Planned Corrective Action USDBC management acknowledges finding 2024-001 made by Rood & Dinis, LLP during its financial statement audit for the fiscal year ended December 31, 2024. USDBC will submit a revised Fraud Prevention Program to FAS for approval. USDBC believes that their cu...

FINDING 2024-001 Planned Corrective Action USDBC management acknowledges finding 2024-001 made by Rood & Dinis, LLP during its financial statement audit for the fiscal year ended December 31, 2024. USDBC will submit a revised Fraud Prevention Program to FAS for approval. USDBC believes that their current internal control framework is appropriately designed to mitigate fraud. Responsible Party Danny Raulerson, Executive Director Completion Date September 30, 2025

View Audit 367915

Finding 1155650 (2024-001)

Material Weakness 2024

D'youville Elderly Housing Corporation

MA

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties

To whom it may concern: D’Youville Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assig...

To whom it may concern: D’Youville Elderly Housing Corporation respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Supportive Housing for the Elderly (Section 202) Assistance Listing Number: 14.157 Award Period: Year ended December 31, 2024 Criteria: Federal regulations require that projects make required deposits to the replacement reserve account monthly. Condition: In May 2024, the Project’s required monthly replacement reserve amount was increased. Questioned Costs: $661 Context: It was noted that eight of the twelve monthly deposits to the replacement reserve account were below the required monthly deposit amount. Effect: The replacement reserve account was underfunded. Recommendation: We recommend that funding amounts to the replacement reserve account be reviewed by an appropriate level of management, especially when there are changes to the required monthly deposit. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will implement procedures to ensure proper review of the monthly deposits. The $661 shortfall was deposited to the replacement reserve account in 2025. Name of contact person responsible for correction action: Corrinne Schindler.

View Audit 367901 Questioned Costs: $1

Finding 1155648 (2024-001)

Material Weakness 2024

D'youville Senior Living, Inc.

MA

Questioned Costs Allowable Costs / Cost Principles Significant Deficiency

To whom it may concern: D’Youville Senior Living, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in t...

To whom it may concern: D’Youville Senior Living, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program: Supportive Housing for the Elderly (Section 202) Assistance Listing Number: 14.157 Award Period: Year ended December 31, 2024 Criteria: Federal regulations require that project funds may only be used for expenses that are reasonable and necessary to the operation of the project. Condition: The Project’s internal controls related to cash disbursements state that expenditures be authorized to ensure they relate to that project and shared costs are properly allocated between the sole member’s projects. Questioned Costs: $24,331 Context: It was noted that there were five instances where cash disbursements were made to the project’s related parties for costs allocated to the project that were subsequently discovered to be erroneously charged to the project. Effect: Expenses were paid out of project funds that did not relate to the project. Recommendation: We recommend that all allocated intercompany costs be reviewed by an appropriate level of management before being charged to the project. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will implement procedures to ensure proper allocation and documentation of intercompany transactions. $15,163 has been returned to the project as of December 31, 2024 and the remaining balance was returned in 2025. Name of contact person responsible for corrective action: Corrinne Schindler.

View Audit 367899 Questioned Costs: $1

Finding 1155629 (2024-003)

Material Weakness 2024

Town of Bellingham, Massachusetts

MA

Significant Deficiency Internal Control / Segregation of Duties

Finding 2024-003 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Complianc...

Finding 2024-003 – Education Stabilization Fund – AL No.’s 84.425D & 84.425U Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: Where employees work solely or partially on a single Federal program or cost objective, their salaries or wages must be supported by periodic certification that the employee worked on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the Town was not able to provide evidence that the required certifications of time and effort for those employees whose time was spent either completely or partially spent on these programs was performed as required by Uniform Guidance. Questioned Costs: Unknown Context: During our test of payroll transactions of the major programs (Education Stabilization Fund and Special Education Cluster) it was noted that the time and effort certifications for the employees tested were not singed by the supervisory official. Effect: The Town was not in compliance with the time and effort certification requirements. Cause: The District has made great efforts to ensure time and effort certification compliance. While the District is having the Supervisor execute and approve timesheets for payment, the Supervisor’s signature was omitted from the Time & Effort Certification. The District is issuing Time & Effort Certifications to all employees working and being paid from a Federal grant semi-annually, including sending Certified Mail, Return Receipt documentation to former employees. Identification as a Repeat Finding: 2023-004 Recommendation: We recommend the Town of Bellingham follow procedures to ensure that semi-annual certifications and/or monthly certifications are prepared and signed by either the employees and/or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Director of Finance Estimated Completion Date: January 1, 2026 Action Taken: The District will incorporate the Supervisor’s signature to all Time & Effort Certifications immediately upon this finding, January 1, 2026.

View Audit 367881

Finding 1155621 (2024-001)

Material Weakness 2024

Downstreet Housing and Community Development, Inc.

VT

Allowable Costs / Cost Principles Reporting Significant Deficiency

Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal contro...

Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal control procedures require the Vermont Housing Improvement Program (VHIP) expenditure tracking spreadsheets to be updated and reviewed prior to disbursements of VHIP grant funds to grant awardees. Condition: During testing of the VHIP grant fund disbursement process, the auditor found that the control designed to ensure all payments were supported by adequate documentation was not operating effectively. Corrective action plan: Downstreet has revised the VHIP approval process to ensure invoices and tracking sheets are verified before disbursement, with documentation uploaded to client files. Staff roles within the Homeownership Center have been realigned to improve accuracy, and a new staff member now supports the program, with responsibilities that include auditing files at disbursement to confirm completeness. All corrective actions have been implemented as of September 2025. Responsible official: Schuyler Anderson, CFO/COO

View Audit 367878

Finding 1155546 (2024-007)

Material Weakness 2024

Itasca County

MN

Internal Control / Segregation of Duties Reporting Significant Deficiency

REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community H...

REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the County ensure each report is reviewed by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each report is reviewed by someone other than the preparer. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025

View Audit 367845

Finding 1155538 (2024-008)

Material Weakness 2024

Itasca County

MN

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency

SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of the Treasury Federal Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number: 21.027 Pass-Through Agency: Not applicable, direct Federal Award Identification Number and Pass-Through Number:...

SUSPENSION AND DEBARMENT Federal Agency: U.S. Department of the Treasury Federal Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Assistance Listing Number: 21.027 Pass-Through Agency: Not applicable, direct Federal Award Identification Number and Pass-Through Number: Not applicable, direct Compliance Requirement Affected: Suspension and Debarment Award Period: Year Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: We recommend the County review their procedures to ensure they are following their policy that requires all suspension and debarment checks to be retained and follow federal guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each report is reviewed by someone other than the preparer. Name of the contact person responsible for corrective action: Gail Guck, Accounting Manager Planned completion date for corrective action plan: December 31, 2025

View Audit 367845

Finding 1155511 (2024-004)

Material Weakness 2024

Shatterproof A Nonprofit Corporation

CT

Cash Management Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Cash Management Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof implement contro...

Cash Management Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof implement controls to ensure anadequate review process is in place to review reimbursement requests to determine anddocument the request is properly supported and in compliance with the grant agreement. Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: State Directors review and approve all invoices prior to submission to the state. Name of the contact person responsible for corrective action: Young Kim Planned completion date for corrective action plan: January 1st, 2025

View Audit 367790

Finding 1155510 (2024-003)

Material Weakness 2024

Shatterproof A Nonprofit Corporation

CT

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Sh...

Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof ensure internal controls are in place and operating effectively so that when changes in vendors involved in the financial reporting process occur there is an evaluation of the electronic evidence of the performance of internal controls and other data to ensure needed documentation is retained or continues to be accessible in line with their record retention policies and requirements of the grant agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2024, Shatterproof implemented Bill Spend & Expense (Divvy), a cloud-based platform designed to automate receipt tracking, provide a clear audit trail for expense coding, and support a streamlined approval workflow. Name of the contact person responsible for corrective action: Young Kim Planned completion date for corrective action plan: 4/1/2024

View Audit 367790 Questioned Costs: $1

Finding 1155461 (2024-002)

Material Weakness 2024

Aid Upstate

SC

Cash Management Significant Deficiency

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reim...

Contact Person: Tracy Carr, Rajee Rao Management Response: We agree with the auditors’ comments and the following action plan will be taken to implement internal control procedures to allow for timely reporting: A schedule has been developed which has enabled the submission of the monthly grant reimbursement reports by the due date. It has required a group effort by the entire staff and the individual members of the finance team in the responsibilities to meet the deadline. The continued use of this schedule has proven to keep the process on track and allow the organization to adhere to the grant deadlines. Completion Date: Beginning June 1, 2024 and thereafter.

View Audit 367743

Finding 1155384 (2024-001)

Material Weakness 2024

Cheyenne Health and Wellness Center Doing Business As Healthworks

WY

Reporting Allowable Costs / Cost Principles Material Weakness

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. ...

2024-001 Reporting Corrective action planned: For employee expenses calculation for the Uniform Data System (UDS) reporting annual accrued PTO calculations will not be used. Anticipated completion date: Complete date of this corrective action plan is immediate. The next UDS report is due 2/15/2026. For the 2025 UDS report accrued PTO for employees will not be included employee expenses. Contact person responsible for corrective action: Margaret Cox CFO mcox@wyhealthworks.org

View Audit 367639

Finding 1155370 (2024-004)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties Significant Deficiency

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1...

Corrective Action Plan: All residents of House of Jospeh Permanent Residence are being recertified to ensure that compliance requirements are being met. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: October 1, 2025

View Audit 367616

Finding 1155369 (2024-003)

Material Weakness 2024

The Ministry of Caring, INC

DE

Eligibility Internal Control / Segregation of Duties HUD Housing Programs

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Ac...

Corrective Action Plan: This matter has in effect self-corrected. The client in question no longer works a number of hours that would cause him to exceed the income threshold. The need to be mindful of his income has been expressed to the client directly. Contact Person Responsible for Corrective Action: Eugene Halus, Chief Operating Officer Anticipated Completion Date of Corrective Action: September 18, 2025

View Audit 367616

Finding 1155367 (2024-001)

Material Weakness 2024

Suffolk County, New York

NY

Eligibility Subrecipient Monitoring Significant Deficiency § 200.303

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant...

REFERENCE No. 2024-001 Significant Deficiency in Internal Control Over Compliance, Other Matters - Eligibility Program Medicaid Cluster (Assistance Listing Number 93.778) Identification Number(s) DOH01-C37308GG-3450000 Finding The County did not maintain adequate documentation of program participant eligibility, nor did it ensure that non-long-term care program participants were properly classified. Sixty participants were selected for testing and the following exceptions were noted: • For five of sixty participants selected for testing, the County was unable to provide documentation that a program supervisor had approved the application. • For one of sixty participants selected for testing, the County was unable to provide a signed participant application. • For one of sixty participants selected for testing, upon reapplication and further documentation, a long-term care case was determined to be non-long-term care, but the County did not make this change and the participant was misclassified. Questioned Costs Undetermined. Recommendation The County should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility. It should also enhance procedures and internal controls to ensure participants are correctly classified as long-term care versus non-long-term care. Corrective Action Plan The Medicaid Division will continue to emphasize the need for signatures at both levels of eligibility Examiner level and Quality Control Examiner II or higher level. This will be stressed at all appropriate training for not only new staff but current staff as well. As far as the “misclassified” the Consumer left nursing home during a period when documentation requirements were waived, due to the Public Health Emergency (COVID-19); The coverage was correct, but coding indicated the need for Long Term Care. This code does not allow or authorize any services on its own, and as such, no inappropriate services were authorized. Even though this has little impact the Division will continue to stress to staff and supervisors the need to properly code cases. NYS DOH is in the process of transitioning away from LDSS 3209 forms and automating the process; we will continue to work with our state partners to assist in this transition when it becomes available to us. This transition should mitigate these type of situations. Action Date September 5, 2025 Final Implementation Date December 31, 2025 Name And Phone No. Of Person Responsible For Implementation James Sluder – 631-854-5830

View Audit 367602

Finding 1155354 (2024-002)

Material Weakness 2024

Goodwill Industries of Michiana, Inc.

IN

Cash Management Significant Deficiency Internal Control / Segregation of Duties

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to...

2024-002 PAYROLL POPULATION The Organization uses general ledger detail to create draws to submit reimbursement claims. Some reimbursements are for payroll expenses that are paid through a separate system. The Organization could not reconcile the general ledger to the payroll software detail used to submit reimbursements. Recommendation: The Organization should perform and maintain monthly reconciliations of the payroll software, general ledger, and draw detail that all agree. Action Taken: The Organization was billing the grantor for payroll fees, the additional fees for each employee or contract that participated in the grant. Originally, the funds were coded to payroll (compensation) expenses, which generated a discrepancy between the Payroll Register and the General Ledger. The unemployment expense was also coded to benefits, which created a variance between the payroll register (generated from payroll software) and the general ledger. Going forward, the trail balance and general ledger will be reconciled to the draw request. Additionally, the team has been trained in how to properly code these expenses. Contact Person: Shire Kuch Effective Date: 25 September 2025.

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