Corrective Action Plans

Finding 1223676 (2025-003)

Material Weakness 2025

MN

Questioned Costs Cash Management HUD Housing Programs § 200.303

Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges...

Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges this finding. City has communicated directly with Housing and Urban Development for clarification on reporting requirements and intends on following the updated guidance they provided. Anticipated Completion Date: July 31, 2026

View Audit 407178

Finding 1223628 (2025-001)

Material Weakness 2025

Town of Stoughton

MA

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...

The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director

View Audit 407123

Finding 1223625 (2025-004)

Material Weakness 2025

Indiana Diaper Bank, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...

Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.

View Audit 407121

Finding 1223592 (2025-002)

Material Weakness 2025

Metropolitan Development Council

WA

Questioned Costs Special Tests & Provisions Allowable Costs / Cost Principles

See pdf of corrective action plan

View Audit 407034

Finding 1223590 (2025-001)

Material Weakness 2025

Metropolitan Development Council

WA

Questioned Costs Eligibility Significant Deficiency

See pdf of corrective action plan

View Audit 407034

Finding 1223576 (2025-001)

Material Weakness 2025

Cowlitz Family Health Center

WA

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

Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended Decem...

Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Summary of finding: Testing of 40 patient encounters identified 2 instances in which the sliding fee discount schedule (SFDS) was not applied in accordance with established requirements. These instances included the incorrect application of the sliding fee scale and the failure to apply the discount when required. As a result, certain patients were undercharged or overcharged for services received. Planned corrective action: CFHC management concurs with the finding. CFHC has policies and procedures in place to ensure compliance. CFHC will provide additional training to the Patient Services Representatives and Billing Clerks to ensure the existing policies and procedures are followed. The CFHC Billing Manager will develop additional reviews to discover, correct, and educate when non-compliance is suspected. CFHC will provide targeted trainings as necessary for site level personnel. Monitoring and review will be an ongoing effort as the positions responsible for real-time compliance tend to be highly transitory. Additional review steps have already been implemented and will become part of the typical workflows to monitor compliance. Anticipated Completion Date: June 1, 2026 Contact Person: Jim Merrill, Chief Financial Officer Email: jmerrill@cfamhc.org Phone: 360-703-6701 Name and Address of Independent Public Accounting Firm: Aprio, LLP 3 Centerpointe Dr, Ste 300 Lake Oswego, OR 97035

View Audit 407001

Finding 1223572 (2025-002)

Material Weakness 2025

Family Health Care of Northwest Ohio Inc.

OH

Questioned Costs Eligibility Significant Deficiency

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically tes...

Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026

View Audit 406997

Finding 1223561 (2025-002)

Material Weakness 2025

Aultman Health Foundation

OH

Questioned Costs Reporting Significant Deficiency

2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control proces...

2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control processes over COD reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This system error has been corrected and additional training offered to bursar’s office. Name(s) of the contact person(s) responsible for corrective action: Wendy Davis Planned completion date for corrective action plan: 06/26/2026

View Audit 406965

Finding 1223159 (2025-006)

Material Weakness 2025

Hillcrest Family Services, INC

IA

Reporting Questioned Costs Significant Deficiency

Finding 2025-006 Reporting Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reporting, there was no documentation ...

Finding 2025-006 Reporting Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reporting, there was no documentation available for the review and approval procedures performed for one of the reports tested. Responsible Individuals: Janet Warren, Director of Financial Operations Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over reporting. In the future, management will ensure that documentation of the approval process for reporting is kept. Anticipated Completion Date: June 5, 2026.

View Audit 406681

Finding 1223158 (2025-005)

Material Weakness 2025

Hillcrest Family Services, INC

IA

Cash Management Questioned Costs Significant Deficiency

Finding 2025-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reimbursement requests, there wa...

Finding 2025-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reimbursement requests, there was no documentation available for the review and approval procedures performed. Responsible Individuals: Janet Warren, Director of Financial Operations Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over cash management. In the future, management will ensure that documentation of the approval process for reimbursement is kept. Anticipated Completion Date: June 5, 2026.

View Audit 406681

Finding 1223157 (2025-004)

Material Weakness 2025

CLEAN ENERGY FUND OF TEXAS, INC.

TX

Questioned Costs Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.430

Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that r...

Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that reviews were not performed. To address this finding, management has implemented a formal, documented review process for timesheets and payroll prior to disbursement. Timesheets will be reviewed and approved through a centralized system or documented workflow to ensure that evidence of supervisory review is retained. Payroll changes require CEO approval prior to or concurrent with processing and documentation retained. Each payroll is subject to independent review and confirmation. Cumulative payroll and allocation are further subject to independent quarterly review by the CEO with supporting documentation. These procedures will be incorporated into standard operating practices and monitored periodically to ensure consistent application and retention of audit evidence. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations

View Audit 406679

Finding 1223147 (2025-002)

Material Weakness 2025

CLEAN ENERGY FUND OF TEXAS, INC.

TX

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Allowable Costs / Cost Principles § 200.318 § 200.320

Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and docum...

Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and documentation gaps associated with system transitions. To address this finding, management has implemented corrective actions requiring documented, written approval for procurements prior to execution. The organization will use standardized approval workflows to ensure procurement approvals are properly evidenced, retained, and available for audit review. Management has also established a centralized repository for procurement records to improve accessibility, consistency, and document retention. In addition, management will enhance data backup and migration procedures to reduce the risk of documentation loss during future system transitions. These procedures will be incorporated into formal policies and standard operating procedures. Management will monitor compliance to ensure procurement documentation and approval controls are consistently followed across federally funded programs. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations

View Audit 406679

Finding 1223138 (2025-005)

Material Weakness 2025

Puerto Rico Ports Authority

PR

Questioned Costs Reporting Significant Deficiency § 200.512

Finding No. 2025-005 – Late filing of data collection form and reporting package Condition The Authority did not submit the required data collection form and reporting package within the required period by March 31, 2026 (9 months after the end of fiscal year). Views of Responsible Officials and Cor...

Finding No. 2025-005 – Late filing of data collection form and reporting package Condition The Authority did not submit the required data collection form and reporting package within the required period by March 31, 2026 (9 months after the end of fiscal year). Views of Responsible Officials and Corrective Actions The Federal Funds Management Office (FFMO) is aware of the deadlines for filing the data collection form and the reporting package, however, as indicated in previous year’s audits, the completion of the required information continues out of their control. In addition, to having difficulties with its monthly accounting closings due to personnel limitations in the Accounting Office, the implementation of new accounting standards, such as GASBs No. 73, N0. 75, No. 87 and others have been additional obstacles to achieve our objective to file the data collection form and reporting package timely. Accordingly, it has not been possible to complete the audit of the financial statements and the single audits for various fiscal years on time, nor to file the data collection form and the reporting packages. In August 2025 and January 2026, the audited financial statements for 2024 and 2025, respectively were issued. Also, the Authority’s management expects to issue the 2026 financial statements during December 2026. Management will continue emphasizing to the FFMO that reports need to be submi􀄴ed on a timely basis. Management will do its best to procure additional personnel for the Accounting and Federal Funds Management Offices. Once a final catch-up of the timely issuance of the audited financial statements is achieved, the required information will be filed within the timeframe established by federal regulations. Name(s) of the Contact Person(s) Responsible for Corrective Action Romel Pedraza Claudio. P.E. – Assistant Executive Director for Planning & Engineering Luis R. Torres Meléndez – Federal Funds Area Officer José Mojica Bonet – Federal Funds Area Officer Anticipated Completion Date Once the Authority catches up with the financial statements’ issuance, the data collection form and reporting package will be filed timely.

View Audit 406665

Finding 1223030 (2025-001)

Material Weakness 2025

West Valley Housing Authority

OR

HUD Housing Programs Internal Control / Segregation of Duties Questioned Costs

CORRECTIVE ACTION PLAN -For FY 2025 Audit Finding FINDING: 2025-001-ALN 14.871 & 14.879: U.S. Department of Housing and Urban Development’s (HUD’s) Section 8 Housing Choice Voucher (HCV) Program & Housing Quality Standards Inspection/HQS Enforcement CRITERIA: 24 CFR 982.405 & 983.103 require units l...

CORRECTIVE ACTION PLAN -For FY 2025 Audit Finding FINDING: 2025-001-ALN 14.871 & 14.879: U.S. Department of Housing and Urban Development’s (HUD’s) Section 8 Housing Choice Voucher (HCV) Program & Housing Quality Standards Inspection/HQS Enforcement CRITERIA: 24 CFR 982.405 & 983.103 require units leased, under the HCV Program, to be inspected at least biennially to determine if the unit meets Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. CONDITION: During the audit, three (3) failed HQS inspections, with life threatening issues as defined by the WVHA’s Administrative Plan, was found that did not receive a pass in conformance with the Criteria noted above and no HAP abatement process was enforced. Additionally, two (2) HCV units were found to have not been inspected at least biennially. PLAN FOR CORRECTION: Inspection Protocols- With the limitation of time imposed by the 24-hour remedy period, staff were calling and/or emailing the landlords as soon as they noted a Life, Health & Safety deficiency. Inspection staff have been informed that all Life Health and Safety deficiencies will immediately trigger a letter to the landlord (with a copy to the HCV caseworker) stating that Housing Assistance Payments will be placed in abatement and the HCV caseworkers will perform such abatement action as soon as the 24-hour period has elapsed (unless informed by the inspector that the property has subsequently corrected the deficiencies). Documentation- Physical inspection records will be provided to each HCV caseworker and be added to the tenant household’s HCV file within 24 hours of the inspection. HCV caseworkers are required to ensure all inspection documentation is properly located within each HCV file and such documentation is in accordance with the program’s rules and regulations. CONTACTS FOR PLAN: Cheryl Slagle – Housing Programs Manager Ph. (503) 623-8387 Ext. 328 cslagle@wvpha.org Christian Edelblute - Executive Director Ph. (503) 623-8387 Ext. 314 cedelblute@wvpha.org

View Audit 406612

Finding 1222980 (2025-007)

Material Weakness 2025

Cherokee Boys Club, Inc.

NC

Special Tests & Provisions Questioned Costs Subrecipient Monitoring

Finding 2025-007: Significant Deficiency - Special Tests and Provisions Condition: The Club notified the contractor of the wage rate requirements but did not obtain or review certified payroll records for each week in which work was performed under the contract. Corrective Action: The Club Finance D...

Finding 2025-007: Significant Deficiency - Special Tests and Provisions Condition: The Club notified the contractor of the wage rate requirements but did not obtain or review certified payroll records for each week in which work was performed under the contract. Corrective Action: The Club Finance Director will work with the current contractor and set up a schedule for payroll review based on their payroll schdule. Person Responsible For Corrective Action: Rhonica Via, Finance Director Anticipated Completion Date: July 31, 2026

View Audit 406502

Finding 1222975 (2025-004)

Material Weakness 2025

Cherokee Boys Club, Inc.

NC

Special Tests & Provisions Questioned Costs Significant Deficiency

Finding 2025-004: Significant Deficiency - Special Tests and Provisions Repeat of Prior Year Finding 2024-005 Condition: While documentation exists that a background investigation was completed, no documentation was maintained that the results of the background investigation were compared to the emp...

Finding 2025-004: Significant Deficiency - Special Tests and Provisions Repeat of Prior Year Finding 2024-005 Condition: While documentation exists that a background investigation was completed, no documentation was maintained that the results of the background investigation were compared to the employment application or that a suitability determination was conducted by an appropriate adjudicating official who herself/himself was the subject of a favorable background investigation. Corrective Action: The Club and Cherokee Central Schools (CCS) agree with this finding and CCS notes that its Employment Suitability Investigations policy was updated and formally adopted on July 22, 2019. The audit included a sample of employee files from prior years, before the policy was implemented and before consistent personnel changes were made. Since the policy's adoption, appropriate procedures have been put in place to ensure background investigations and employment suitability assessments are conducted and properly documented. CCS will continue to monitor compliance with the policy and ensure that documentation is consistently maintained in employee personnel files moving forward. Current updates to be enacted immediately include documentation that the Superintendent has reviewed the files. Person Responsible For Corrective Action: Heather Driver, Interim CCS HR Director Anticipated Completion Date: June 30, 2026

View Audit 406502

Finding 1222968 (2025-002)

Material Weakness 2025

Sicangu Oyate Ho, INC

SD

Reporting Significant Deficiency

Management Response: Management acknowledges the audit finding related to the late submission of the Single Audit, which was identified as a significant deficiency. We recognize the importance of timely submission in accordance with federal audit requirements and applicable regulatory deadlines. Man...

Management Response: Management acknowledges the audit finding related to the late submission of the Single Audit, which was identified as a significant deficiency. We recognize the importance of timely submission in accordance with federal audit requirements and applicable regulatory deadlines. Management has evaluated the audit timeline process and identified delays in the coordination of year-end financial reporting, supporting documentation, and audit fieldwork completion. We have reviewed our processes for fiscal year end closing and are committed to ensuring timely completion and submission of future Single Audits. Anticipated Completion Date: Immediately upon the start of the new Fiscal Year on July 1.Management anticipates full implementation by July 30, 2027. Responsible Party: All Business Office Staff. 39

View Audit 406467

Finding 1222938 (2025-006)

Material Weakness 2025

Help Usa, Inc. and Affiliates

NY

Questioned Costs Reporting Significant Deficiency

Management has established a documentation tracking system to ensure that all stages of the monthly reporting process including preparation, review, approval, and submission are properly documented and retained.

View Audit 406443

Finding 1222936 (2025-005)

Material Weakness 2025

Help Usa, Inc. and Affiliates

NY

Questioned Costs Eligibility Significant Deficiency

Management has implemented a comprehensive continuing education program for employees who work on the SSVF program. Monthly internal audits are conducted by the Program leadership team to monitor compliance with funder guidelines.

View Audit 406443

Finding 1222891 (2025-001)

Material Weakness 2025

City of Akron, Ohio

OH

Subrecipient Monitoring Reporting Significant Deficiency § 200.208 § 200.328

The City will implement additional control procedures to ensure all reports are filed in a timely manner.

View Audit 406417

Finding 1222844 (2025-002)

Material Weakness 2025

Municipality of Cidra

PR

Questioned Costs Reporting Significant Deficiency § 200.512

We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement. Implementation Date: During the 2026-2027 fiscal year. Responsible Person: Mrs. Yadira Pereira Nieves Finance Director

View Audit 406403

Finding 1222839 (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 406402

Finding 1222773 (2025-002)

Material Weakness 2025

CITY STAPLES

MN

Reporting Significant Deficiency

Preparation of Financial Statements and Related Footnotes

View Audit 406340

Finding 1222773 (2025-002)

Material Weakness 2025

CITY STAPLES

MN

Reporting Significant Deficiency

Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.

View Audit 406340

Finding 1222773 (2025-002)

Material Weakness 2025

CITY STAPLES

MN

Reporting Significant Deficiency

Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal e...

Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.

View Audit 406340

Corrective Action Plans

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